Healthcare Provider Details

I. General information

NPI: 1952615387
Provider Name (Legal Business Name): KACIE T TISDALE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KACIE T ROBERTUS FNP

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S 27TH ST
BILLINGS MT
59101-4227
US

IV. Provider business mailing address

2510 17TH ST W
BILLINGS MT
59102-1736
US

V. Phone/Fax

Practice location:
  • Phone: 406-247-3350
  • Fax: 406-247-3389
Mailing address:
  • Phone: 406-245-3238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number32201
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number32201
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: