Healthcare Provider Details

I. General information

NPI: 1235022625
Provider Name (Legal Business Name): TONYA R TIDWELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 DEER TRACK DR
HAMILTON AL
35570-9679
US

IV. Provider business mailing address

175 DEER TRACK DR
HAMILTON AL
35570-9679
US

V. Phone/Fax

Practice location:
  • Phone: 205-412-1434
  • Fax:
Mailing address:
  • Phone: 205-412-1434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-102367
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: