Provider Demographics
NPI:1700295284
Name:TIDD, NICOLE LYNN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:TIDD
Suffix:
Gender:F
Credentials:
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 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-2200
Mailing Address - Fax:803-395-2237
Practice Address - Street 1:1137 COOK RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8204
Practice Address - Country:US
Practice Address - Phone:803-531-0970
Practice Address - Fax:803-395-2237
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18998363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6199OtherMEDICAID GROUP NUMBER