Healthcare Provider Details

I. General information

NPI: 1558970939
Provider Name (Legal Business Name): JENNIFER BAREFOOT TIDWELL NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER BAREFOOT

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4131
  • Fax: 336-713-0328
Mailing address:
  • Phone: 336-716-0238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF07202295
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5013567
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: