Provider Demographics
NPI:1629674981
Name:TIDWELL, CORNEISHA LATRAY
Entity Type:Individual
Prefix:
First Name:CORNEISHA
Middle Name:LATRAY
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 1:443 BALLYCLARE TER
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-4001
Mailing Address - Country:US
Mailing Address - Phone:513-372-2371
Mailing Address - Fax:
Practice Address - Street 1:443 BALLYCLARE TER
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-4001
Practice Address - Country:US
Practice Address - Phone:513-372-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH40088591009253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care