Provider Demographics
NPI:1780959452
Name:TIDWELL, NORMA B (NA)
Entity type:Individual
Prefix:MRS
First Name:NORMA
Middle Name:B
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:NA
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 418
Mailing Address - Street 2:162 SHARP-PERKINS RD.
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-0418
Mailing Address - Country:US
Mailing Address - Phone:423-562-8351
Mailing Address - Fax:423-562-1593
Practice Address - Street 1:162 SHARP AND PERKINS RD
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-2507
Practice Address - Country:US
Practice Address - Phone:423-562-8351
Practice Address - Fax:423-562-1593
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide