Healthcare Provider Details

I. General information

NPI: 1396960498
Provider Name (Legal Business Name): JUDITH YEAGER TIDDY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUDITH AILEEN YEAGER NP

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WALTER REED ARMY MEDICAL CTR 6900 GEORGIA AVE., NW
WASHINGTON DC
20307-0001
US

IV. Provider business mailing address

900 RAMSEY ST
ALEXANDRIA VA
22301-2130
US

V. Phone/Fax

Practice location:
  • Phone: 202-782-7341
  • Fax:
Mailing address:
  • Phone: 202-782-9325
  • Fax: 202-782-4313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN966388
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: