Provider Demographics
NPI:1992840383
Name:TIDWELL, HEATHER NICHOL (PTA)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:NICHOL
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-0900
Mailing Address - Country:US
Mailing Address - Phone:615-417-3817
Mailing Address - Fax:
Practice Address - Street 1:3658 BELL RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37214-2600
Practice Address - Country:US
Practice Address - Phone:615-391-0525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3352174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist