Provider Demographics
NPI:1740949668
Name:JANICEK, ANGELA TIDWELL (APRN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:TIDWELL
Last Name:JANICEK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:327 CALDWELL DR STE 500
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3410
Mailing Address - Country:US
Mailing Address - Phone:615-239-1404
Mailing Address - Fax:
Practice Address - Street 1:327 CALDWELL DR STE 500
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3410
Practice Address - Country:US
Practice Address - Phone:615-239-1404
Practice Address - Fax:615-900-2716
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31500363LP0808X, 363L00000X, 363LP0808X
TN141667163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner