Provider Demographics
NPI:1649466798
Name:TIDWELL, TERRY (LVN)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 833
Mailing Address - Street 2:
Mailing Address - City:SPRINGTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:76082-0833
Mailing Address - Country:US
Mailing Address - Phone:817-523-3084
Mailing Address - Fax:
Practice Address - Street 1:436 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGTOWN
Practice Address - State:TX
Practice Address - Zip Code:76082-2608
Practice Address - Country:US
Practice Address - Phone:817-523-3084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-22
Last Update Date:2007-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136181164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136181OtherLVN