Provider Demographics
NPI:1235995952
Name:TIDWELL, SHANICE R
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:R
Last Name:TIDWELL
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 1:16867 KINGSBURY ST APT 126
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-6444
Mailing Address - Country:US
Mailing Address - Phone:513-809-3962
Mailing Address - Fax:
Practice Address - Street 1:16867 KINGSBURY ST APT 126
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6444
Practice Address - Country:US
Practice Address - Phone:513-809-3962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)