Healthcare Provider Details

I. General information

NPI: 1700295284
Provider Name (Legal Business Name): NICOLE LYNN TIDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1137 COOK RD
ORANGEBURG SC
29118-8204
US

IV. Provider business mailing address

PO BOX 1245
ORANGEBURG SC
29116-1245
US

V. Phone/Fax

Practice location:
  • Phone: 803-531-0970
  • Fax: 803-395-2237
Mailing address:
  • Phone: 803-395-2200
  • Fax: 803-395-2237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number18998
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number18998
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: