Provider Demographics
NPI:1750865150
Name:TIDD, DANYELLE MARIE (RN)
Entity Type:Individual
Prefix:
First Name:DANYELLE
Middle Name:MARIE
Last Name:TIDD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 CONEMAUGH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-1728
Mailing Address - Country:US
Mailing Address - Phone:724-967-2130
Mailing Address - Fax:
Practice Address - Street 1:401 BROAD ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15906-2716
Practice Address - Country:US
Practice Address - Phone:814-535-6000
Practice Address - Fax:814-248-7901
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN548194163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA163WOOOOOXMedicaid