Provider Demographics
NPI:1609684802
Name:TIDWELL, EMILY NICOLE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:NICOLE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7417
Mailing Address - Country:US
Mailing Address - Phone:870-613-5890
Mailing Address - Fax:
Practice Address - Street 1:2236 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7417
Practice Address - Country:US
Practice Address - Phone:870-613-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR221019164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse