Healthcare Provider Details

I. General information

NPI: 1104074822
Provider Name (Legal Business Name): KELLI D TIDWELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2008
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 DOWELL SPRINGS BLVD SUITE 300
KNOXVILLE TN
37909
US

IV. Provider business mailing address

1450 DOWELL SPRINGS BLVD SUITE 300
KNOXVILLE TN
37909
US

V. Phone/Fax

Practice location:
  • Phone: 865-637-8812
  • Fax: 865-637-8865
Mailing address:
  • Phone: 865-637-8812
  • Fax: 865-637-8865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN0000007947
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: