Individual
LATIA TISDALE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2520 PROFESSIONAL RD STE D, NORTH CHESTERFIELD, VA 23235-3267
(804) 601-4447
Mailing address
6313 CALAVETTI DR, NORTH CHESTERFIELD, VA 23234-4180
(804) 405-0009
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
1204019942
VA
Other
Enumeration date
02/08/2020
Last updated
02/08/2020
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