Healthcare Provider Details

I. General information

NPI: 1194385591
Provider Name (Legal Business Name): KRISTINE EILEEN TIDSWELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 S TAMIAMI TRL
SARASOTA FL
34239-2219
US

IV. Provider business mailing address

7931 LIMESTONE LN
SARASOTA FL
34233-3250
US

V. Phone/Fax

Practice location:
  • Phone: 941-366-2360
  • Fax:
Mailing address:
  • Phone: 954-646-9015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11002779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: