Healthcare Provider Details

I. General information

NPI: 1407682362
Provider Name (Legal Business Name): ANNA GRACE TIDMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5960 GETWELL RD STE 212D
SOUTHAVEN MS
38672-7320
US

IV. Provider business mailing address

2950 DOVE CV
HERNANDO MS
38632-7640
US

V. Phone/Fax

Practice location:
  • Phone: 662-228-0130
  • Fax:
Mailing address:
  • Phone: 662-545-1006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS5240
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: