Provider Demographics
NPI:1194385591
Name:TIDSWELL, KRISTINE EILEEN (CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:EILEEN
Last Name:TIDSWELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7931 LIMESTONE LN
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3250
Mailing Address - Country:US
Mailing Address - Phone:954-646-9015
Mailing Address - Fax:
Practice Address - Street 1:1261 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2219
Practice Address - Country:US
Practice Address - Phone:941-366-2360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002779367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000000OtherNONE