Provider Demographics
NPI:1083107254
Name:TIDWELL, MONIQUE SHERRI (NON-EMERGENCY TRANSP)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:SHERRI
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:NON-EMERGENCY TRANSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3531
Mailing Address - Country:US
Mailing Address - Phone:716-322-6198
Mailing Address - Fax:
Practice Address - Street 1:120 EASTON AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3531
Practice Address - Country:US
Practice Address - Phone:716-322-6198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049907272279P4000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P4000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPatient Transport