Healthcare Provider Details

I. General information

NPI: 1851558696
Provider Name (Legal Business Name): REBECCA LYNN TIDWELL PREDILETTO CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 EL CENTRO ST
SOUTH PASADENA CA
91030-3202
US

IV. Provider business mailing address

2489 LOY LN
LOS ANGELES CA
90041-1817
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2229
  • Fax:
Mailing address:
  • Phone: 213-923-4042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: