Provider Demographics
NPI:1912524273
Name:TIDWELL, JONTA DELISA
Entity Type:Individual
Prefix:
First Name:JONTA
Middle Name:DELISA
Last Name:TIDWELL
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 1:3026 18TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6716
Mailing Address - Country:US
Mailing Address - Phone:480-286-8603
Mailing Address - Fax:
Practice Address - Street 1:3026 18TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6716
Practice Address - Country:US
Practice Address - Phone:480-286-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health