Provider Demographics
NPI:1225205677
Name:TIDWELL, LELON DARWIN (RNFA)
Entity Type:Individual
Prefix:
First Name:LELON
Middle Name:DARWIN
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11219
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0219
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:
Practice Address - Street 1:11801 SOUTH FWY
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7021
Practice Address - Country:US
Practice Address - Phone:817-293-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX436290163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX436290OtherRN LICENSE