Healthcare Provider Details

I. General information

NPI: 1073142881
Provider Name (Legal Business Name): MARY ROSE TIDOE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 10/31/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5715 PRINCESS ANNE RD
VIRGINIA BEACH VA
23462-3222
US

IV. Provider business mailing address

311 WOODVIEW AVE
NORFOLK VA
23505-1157
US

V. Phone/Fax

Practice location:
  • Phone: 757-756-7732
  • Fax:
Mailing address:
  • Phone: 757-756-7732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number321854
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024182807
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: