Provider Demographics
NPI:1639715121
Name:TIDWELL, LILLIE
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:
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 1:2332 ISLE ROYALE CT SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4325
Mailing Address - Country:US
Mailing Address - Phone:863-595-6212
Mailing Address - Fax:
Practice Address - Street 1:2332 ISLE ROYALE CT SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4325
Practice Address - Country:US
Practice Address - Phone:863-595-6212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104129000376J00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104851900Medicaid
FL104129000Medicaid