Provider Demographics
NPI:1598964173
Name:VIDALES, TOMMIE (FNP)
Entity Type:Individual
Prefix:
First Name:TOMMIE
Middle Name:
Last Name:VIDALES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336-6507
Mailing Address - Country:US
Mailing Address - Phone:806-894-3141
Mailing Address - Fax:806-894-7094
Practice Address - Street 1:103 JOHN DUPREE DR
Practice Address - Street 2:
Practice Address - City:LEVELLAND
Practice Address - State:TX
Practice Address - Zip Code:79336-6326
Practice Address - Country:US
Practice Address - Phone:806-894-2465
Practice Address - Fax:806-894-8897
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX642208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily