Healthcare Provider Details

I. General information

NPI: 1841398765
Provider Name (Legal Business Name): DEBRA LYNN TIDQUIST APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18601 LINCOLN ST
WHITEHALL WI
54773-8605
US

IV. Provider business mailing address

1251 E WILSON AVE
ARCADIA WI
54612-1830
US

V. Phone/Fax

Practice location:
  • Phone: 715-538-4361
  • Fax: 715-538-2912
Mailing address:
  • Phone: 608-323-7005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2950-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: