Provider Demographics
NPI:1134387558
Name:TIDWELL, JERITHEA DORONICE (RN PHD, PNP, PCNS)
Entity type:Individual
Prefix:DR
First Name:JERITHEA
Middle Name:DORONICE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:RN PHD, PNP, PCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 MEDICAL DISTRICT DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7701
Mailing Address - Country:US
Mailing Address - Phone:214-456-2331
Mailing Address - Fax:214-456-2897
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-2331
Practice Address - Fax:214-456-2897
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000011923363LP0200X, 364SP0200X
TXAP117669364S00000X, 363LP0200X
TX659941364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics