Healthcare Provider Details

I. General information

NPI: 1073862751
Provider Name (Legal Business Name): AMBER NICKOLINA TIDWELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 INDEPENDENCE DR
CARROLLTON GA
30116-9000
US

IV. Provider business mailing address

521 BOYCE RD
CHARLOTTE NC
28211-6166
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-6678
  • Fax:
Mailing address:
  • Phone: 404-578-0479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN125386
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAC004642
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: