Healthcare Provider Details

I. General information

NPI: 1174309298
Provider Name (Legal Business Name): SANDRA TISDALE CNA/BSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7061 VIBURNUM DR
ANCHORAGE AK
99507-2471
US

IV. Provider business mailing address

7061 VIBURNUM DR
ANCHORAGE AK
99507-2471
US

V. Phone/Fax

Practice location:
  • Phone: 907-764-4410
  • Fax:
Mailing address:
  • Phone: 907-764-4410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number168128
License Number StateAS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: