Healthcare Provider Details

I. General information

NPI: 1306199575
Provider Name (Legal Business Name): MONICA MARY TIDWELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MONICA MARY JORDAN-TIDWELL RN

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4531 SE BELMONT ST SUITE 100
PORTLAND OR
97215-1675
US

IV. Provider business mailing address

4531 SE BELMONT ST SUITE 100
PORTLAND OR
97215-1675
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-6556
  • Fax:
Mailing address:
  • Phone: 503-215-6556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number086000069RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: