Provider Demographics
NPI:1578693578
Name:TIDWELL, TIMOTHY WAYNE
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 JOY STREET
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242
Mailing Address - Country:US
Mailing Address - Phone:731-642-4025
Mailing Address - Fax:
Practice Address - Street 1:803 JOY ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4529
Practice Address - Country:US
Practice Address - Phone:731-642-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN63791164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse