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General NPI Number Information
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NPI Number | 1356850739
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Entity Type | Individual
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Provider Name | TONYA L TIDWELL
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Gender | Female
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Dates
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Enumeration Date | 09/28/2017
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Last Update Date | 03/16/2021
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Provider Practice Location Address
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Address Line | 4282 E ROCKTON RD
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City | ROSCOE
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State | IL
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Zip | 61073-7420
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Country | US
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Telephone | 779-696-9000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 78866
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City | MILWAUKEE
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State | WI
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Zip | 53278-8866
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Country | US
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Telephone | 779-696-7150
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 041316348
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209016801
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License Number State | IL
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