Provider Demographics
NPI:1710623426
Name:TIDEMANN, ANGELA LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYNN
Last Name:TIDEMANN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:L
Other - Last Name:JIMERSON EAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:485 VANDERBILT COURT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906
Mailing Address - Country:US
Mailing Address - Phone:719-431-3419
Mailing Address - Fax:
Practice Address - Street 1:600 EVANS RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212
Practice Address - Country:US
Practice Address - Phone:719-269-5058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997260363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily