Provider Demographics
NPI:1700147204
Name:TIDDENS, BROOK ROSE (CNM)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:ROSE
Last Name:TIDDENS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11967 BONNIE LN
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-8056
Mailing Address - Country:US
Mailing Address - Phone:208-761-3497
Mailing Address - Fax:
Practice Address - Street 1:6140 W CURTISIAN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8880
Practice Address - Country:US
Practice Address - Phone:208-367-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife