Healthcare Provider Details

I. General information

NPI: 1235995952
Provider Name (Legal Business Name): SHANICE R TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16867 KINGSBURY ST APT 126
GRANADA HILLS CA
91344-6444
US

IV. Provider business mailing address

16867 KINGSBURY ST APT 126
GRANADA HILLS CA
91344-6444
US

V. Phone/Fax

Practice location:
  • Phone: 513-809-3962
  • Fax:
Mailing address:
  • Phone: 513-809-3962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: