Healthcare Provider Details

I. General information

NPI: 1144867409
Provider Name (Legal Business Name): MARILYN LORETTA TIDWELL -SHOEMAKER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 WINTON BLOUNT LOOP
MONTGOMERY AL
36117-3507
US

IV. Provider business mailing address

233 WINTON BLOUNT LOOP
MONTGOMERY AL
36117-3507
US

V. Phone/Fax

Practice location:
  • Phone: 334-350-5648
  • Fax:
Mailing address:
  • Phone: 334-239-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95013184
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: