Lacy Rebaka Tisdale, NP-C

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

25492 Issued in TN

Practice address

2054 S Highland Ave
Jackson, TN 38301-7741

Phone

(731) 499-8708

Fax

(731) 499-8709

NPI assigned

Dec 11, 2014

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other names 1

• Lacy Thomas Former name

Medicare fee-for-service enrollment

Enrolled in TN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2014

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Fast Pace Medical Clinic PLLCGroup PAC ID 5395881841, 737 clinicians

Healogics Specialty Physicians of Tennessee, PLLCGroup PAC ID 2961720313, 13 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Medical Center Home Health LLC Home health agency, Jackson, TN, CCN 447101
• Jackson-Madison County General Hospital Hospital, Jackson, TN, CCN 440002

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Fast Pace Medical Clinic PLLC

  • Family Medicine Physician
  • Spring Hill, TN
  • NPI 1134452865
  Medicare reassignment Care Compare group NPD
• Healogics Specialty Physicians of Tennessee, PLLC

  • Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
  • Clarksville, TN
  • NPI 1932527090
  Medicare reassignment Care Compare group NPD
• Signify Health Medical Associates, PLLC

  • General Practice Physician
  • Dallas, TX
  • NPI 1750845863

  GA

  Medicare reassignment NPD
• Upperline Healthcare, PC

  • Foot & Ankle Surgery Podiatrist
  • Hoover, AL
  • NPI 1538686498

  TN

  Medicare reassignment NPD
• Fast Pace Medical Clinic PLLC

  • Rural Health Clinic/Center
  • Chapel Hill, TN
  • NPI 1316602774
  NPD
• Upperline Healthcare, PC

  • Foot & Ankle Surgery Podiatrist
  • Ocoee, FL
  • NPI 1326906843
  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Jackson Madison County General Hospital

  • General Acute Care Hospital
  • Jackson, TN
  • NPI 1093705428
  Care Compare affiliation
• Medical Center Home Health, LLC

  • Home Health Agency
  • Jackson, TN
  • NPI 1932355997
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1418256000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1617926400000",
    "number": "1033517768",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "42 CABIN CREEK DIRVE",
            "city": "JACKSON",
            "state": "TN",
            "postal_code": "38305",
            "telephone_number": "870-413-2203"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2054 S HIGHLAND AVE",
            "city": "JACKSON",
            "state": "TN",
            "postal_code": "383017741",
            "telephone_number": "731-499-8708",
            "fax_number": "731-499-8709"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "6806 Mammoth Cv",
            "address_purpose": "LOCATION",
            "city": "Pine Bluff",
            "state": "AR",
            "postal_code": "716034304",
            "country_code": "US",
            "telephone_number": "870-413-2203",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "TISDALE",
        "first_name": "LACY",
        "middle_name": "REBAKA",
        "credential": "NP-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2014-12-11",
        "last_updated": "2021-04-09",
        "certification_date": "2021-03-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "AR",
            "license": "A004241",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "TN",
            "license": "25492",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "LACY",
            "last_name": "THOMAS",
            "credential": "NP-C",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Family Nurse Practitioner in Jackson, TN
• Providers in Jackson, TN by specialty
• Family Nurse Practitioner in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.