Healthcare Provider Details

I. General information

NPI: 1942073218
Provider Name (Legal Business Name): SARAH ELIZABETH TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4237 ATLANTIC AVE
LONG BEACH CA
90807-2801
US

IV. Provider business mailing address

4237 ATLANTIC AVE
LONG BEACH CA
90807-2801
US

V. Phone/Fax

Practice location:
  • Phone: 562-336-1656
  • Fax:
Mailing address:
  • Phone: 562-336-1656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95027903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: