Basic Information
| Provider Information | |||||||||
| NPI: | 1841815784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TISZA | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | DNP, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4056 CLEVELAND AVE APT 1W | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631103959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129530355 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4500 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182337750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2020 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209.021418 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.