Healthcare Provider Details

I. General information

NPI: 1396247276
Provider Name (Legal Business Name): DIANNE TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 03/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 W PARK AVE STE Q-R
GREENWOOD MS
38930-2906
US

IV. Provider business mailing address

860 E RIVER PL STE 100
JACKSON MS
39202-3442
US

V. Phone/Fax

Practice location:
  • Phone: 662-374-5029
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: