Healthcare Provider Details

I. General information

NPI: 1255603932
Provider Name (Legal Business Name): TIFFANY TENEAL TIDWELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-2568
  • Fax: 573-882-2226
Mailing address:
  • Phone: 573-882-3974
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2012008233
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: