Healthcare Provider Details

I. General information

NPI: 1265746820
Provider Name (Legal Business Name): STACY RENEE TIDWELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 04/04/2023
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4618 WILLOW RIDGE WAY
ROGERS AR
72758-8089
US

IV. Provider business mailing address

4618 WILLOW RIDGE WAY
ROGERS AR
72758-8089
US

V. Phone/Fax

Practice location:
  • Phone: 479-587-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA003421
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberA003421
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: