Provider Demographics
NPI:1629878467
Name:WADDELL, TIMOTHY SAMUEL (FNP)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:SAMUEL
Last Name:WADDELL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21460 GOLDEN HILLS BLVD UNIT B
Mailing Address - Street 2:
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-6636
Mailing Address - Country:US
Mailing Address - Phone:336-689-0437
Mailing Address - Fax:
Practice Address - Street 1:21460 GOLDEN HILLS BLVD UNIT B
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-6636
Practice Address - Country:US
Practice Address - Phone:336-689-0437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily