Provider Demographics
NPI:1073142881
Name:TIDOE, MARY ROSE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:TIDOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 WOODVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-1157
Mailing Address - Country:US
Mailing Address - Phone:757-756-7732
Mailing Address - Fax:
Practice Address - Street 1:6160 KEMPSVILLE CIR STE 325
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3933
Practice Address - Country:US
Practice Address - Phone:757-756-7732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182807363LF0000X
NC321854363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty