Basic Information
| Provider Information | |||||||||
| NPI: | 1679963607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TISDALE | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN-FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUGHES | ||||||||
| OtherFirstName: | DANA | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY | ||||||||
| Address2: | SUITE 129 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024895730 | ||||||||
| FaxNumber: | 5024895753 | ||||||||
| Practice Location | |||||||||
| Address1: | 10216 TAYLORSVILLE RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | JEFFERSONTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402993616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022675456 | ||||||||
| FaxNumber: | 5022675488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2015 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3009192 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.