Provider Demographics
NPI:1417297433
Name:TIDWELL, KAREN REBECCA (RN)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:REBECCA
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:REBECCA
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:302 POMONA DR
Mailing Address - Street 2:SUITE L
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1663
Mailing Address - Country:US
Mailing Address - Phone:336-541-6475
Mailing Address - Fax:
Practice Address - Street 1:302 POMONA DR
Practice Address - Street 2:SUITE L
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1663
Practice Address - Country:US
Practice Address - Phone:336-541-6475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251259163W00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator