Provider Demographics
NPI:1669153540
Name:TIDMORE, ALYSSA (MS)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:TIDMORE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:
Other - Last Name:TIDMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:2991 ANGELO JOSEPH LN APT 108
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-0011
Mailing Address - Country:US
Mailing Address - Phone:580-821-1839
Mailing Address - Fax:
Practice Address - Street 1:3535 OLENTANGY RIVER RD FL 1
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3908
Practice Address - Country:US
Practice Address - Phone:614-566-3234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH70.000804TEMP170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS