Healthcare Provider Details

I. General information

NPI: 1386632495
Provider Name (Legal Business Name): TIDEWATER TLC FAMILY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 BATTLEFIELD BLVD N
CHESAPEAKE VA
23320-0305
US

IV. Provider business mailing address

745 BATTLEFIELD BLVD N
CHESAPEAKE VA
23320-0305
US

V. Phone/Fax

Practice location:
  • Phone: 757-436-6959
  • Fax: 757-549-1933
Mailing address:
  • Phone: 757-436-6959
  • Fax: 757-549-1933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VANESSA A BLOWE
Title or Position: PRACTICE OWNER DOCTOR
Credential: MD FAAFP
Phone: 757-436-6959