Provider Demographics
NPI:1306199575
Name:TIDWELL, MONICA MARY (RN)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:MARY
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:MONICA
Other - Middle Name:MARY
Other - Last Name:JORDAN-TIDWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:4531 SE BELMONT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1675
Mailing Address - Country:US
Mailing Address - Phone:503-215-6556
Mailing Address - Fax:
Practice Address - Street 1:4531 SE BELMONT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1675
Practice Address - Country:US
Practice Address - Phone:503-215-6556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR086000069RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health