Provider Demographics
NPI:1265707533
Name:TIDWELL, SHERRY LYNN (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:LYNN
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7723 CLEARVIEW CHURCH LN
Mailing Address - Street 2:
Mailing Address - City:LYLES
Mailing Address - State:TN
Mailing Address - Zip Code:37098-1674
Mailing Address - Country:US
Mailing Address - Phone:931-670-5520
Mailing Address - Fax:931-670-5312
Practice Address - Street 1:7723 CLEARVIEW CHURCH LN
Practice Address - Street 2:
Practice Address - City:LYLES
Practice Address - State:TN
Practice Address - Zip Code:37098-1674
Practice Address - Country:US
Practice Address - Phone:931-670-5520
Practice Address - Fax:931-670-5312
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN92159163W00000X
TN16586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529543Medicaid