Healthcare Provider Details

I. General information

NPI: 1265707533
Provider Name (Legal Business Name): SHERRY LYNN TIDWELL FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7723 CLEARVIEW CHURCH LN
LYLES TN
37098-1674
US

IV. Provider business mailing address

7723 CLEARVIEW CHURCH LN
LYLES TN
37098-1674
US

V. Phone/Fax

Practice location:
  • Phone: 931-670-5520
  • Fax: 931-670-5312
Mailing address:
  • Phone: 931-670-5520
  • Fax: 931-670-5312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number92159
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16586
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: