Healthcare Provider Details

I. General information

NPI: 1477091122
Provider Name (Legal Business Name): MELANI SIDWELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 TUCKER STREET STE 2
JACKSON TN
38301
US

IV. Provider business mailing address

PO BOX 3572
JACKSON TN
38303-3572
US

V. Phone/Fax

Practice location:
  • Phone: 731-668-1853
  • Fax: 731-664-7731
Mailing address:
  • Phone: 731-668-1853
  • Fax: 731-664-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number121210
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: