Healthcare Provider Details

I. General information

NPI: 1669757258
Provider Name (Legal Business Name): LAURA MARIE TIDWELL APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2011
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 N WATER ST STE 600
MILWAUKEE WI
53202-5715
US

IV. Provider business mailing address

342 N WATER ST STE 600
MILWAUKEE WI
53202-5715
US

V. Phone/Fax

Practice location:
  • Phone: 651-342-1039
  • Fax: 651-342-1428
Mailing address:
  • Phone: 651-342-1039
  • Fax: 651-342-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number141543-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5705-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: