MEDICARE: MRS. HEATHER NICHOL TIDWELL P.T.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	3352	TN

General Provider Information

NPI Number	:	1992840383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HEATHER NICHOL TIDWELL P.T.A.

Provider Business Mailing Address
First Line	:	272 DAVIS RD
Second Line	:
City	:	LEBANON
State	:	TN
Zip	:	37087-0900
Country	:	US
Telephone Number	:	615-417-3817
Fax Number	:

Provider Business Practice Location Address
First Line	:	3658 BELL RD
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37214-2600
Country	:	US
Telephone Number	:	615-391-0525
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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