Healthcare Provider Details

I. General information

NPI: 1194476218
Provider Name (Legal Business Name): REBEKAH JO TIDWELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 05/15/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 S LAUREL RD
LONDON KY
40744-6314
US

IV. Provider business mailing address

930 ADELL REE PARK LN
KNOXVILLE TN
37909-2543
US

V. Phone/Fax

Practice location:
  • Phone: 606-657-2030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4035393
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number31028
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: