Healthcare Provider Details

I. General information

NPI: 1811529381
Provider Name (Legal Business Name): IVY TIDWELL PROTHRO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 SANGAMORE RD STE S207
BETHESDA MD
20816-2529
US

IV. Provider business mailing address

4701 SANGAMORE RD STE S207
BETHESDA MD
20816-2529
US

V. Phone/Fax

Practice location:
  • Phone: 202-684-7176
  • Fax:
Mailing address:
  • Phone: 202-684-7167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR241507
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: