Healthcare Provider Details

I. General information

NPI: 1316562549
Provider Name (Legal Business Name): FRANKIE TIDWELL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 SUSANNAH ST
JOHNSON CITY TN
37601-1748
US

IV. Provider business mailing address

226 DE LEE DR
KINGSPORT TN
37663-2611
US

V. Phone/Fax

Practice location:
  • Phone: 423-282-9011
  • Fax:
Mailing address:
  • Phone: 423-817-5512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number27671
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: