Healthcare Provider Details

I. General information

NPI: 1396299525
Provider Name (Legal Business Name): JULIA ANNE TIDIK PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 HIGH ST
SAN LUIS OBISPO CA
93401-5243
US

IV. Provider business mailing address

784 HIGH ST
SAN LUIS OBISPO CA
93401-5243
US

V. Phone/Fax

Practice location:
  • Phone: 805-540-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60469015
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95157097
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60683021
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95009437
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: