Healthcare Provider Details

I. General information

NPI: 1780959452
Provider Name (Legal Business Name): NORMA B TIDWELL NA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 SHARP AND PERKINS RD
JACKSBORO TN
37757-2507
US

IV. Provider business mailing address

PO BOX 418 162 SHARP-PERKINS RD.
JACKSBORO TN
37757-0418
US

V. Phone/Fax

Practice location:
  • Phone: 423-562-8351
  • Fax: 423-562-1593
Mailing address:
  • Phone: 423-562-8351
  • Fax: 423-562-1593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: