Individual
MARY TISDALE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CNM
Contact information
Practice address
1001 MAIN ST STE 300, PEORIA, IL 61606-2036
(309) 495-0200
(309) 676-6545
Mailing address
1025 S 6TH ST, SPRINGFIELD, IL 62703-2403
(217) 528-7541
(772) 879-0436
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
209008217
IL
367A00000X
Advanced Practice Midwife
Primary
209007925
IL
367A00000X
Advanced Practice Midwife
APRN11000699
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9337001
—
IL
Enumeration date
12/10/2009
Last updated
04/05/2021
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