Doctor Name: | MS. AMBER NICKOLINA TIDWELL |
NPI Number: | 1073862751 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | NP |
License Number: | RN125386 |
Business Practice Address: | 20 Herrell Rd Villa Rica, GA - 301805527 |
Business Phone Number: | 7708369551 |
Business Fax Number: | |
Mailing Address: | 20 Herrell Rd, VILLA RICA |
State: | GA |
Postal Code: | 301805527 |
Phone Number: | 7708369551 |
Fax Number: | |
NPI Enumeration Date: | 09/10/2012 |
NPI Last Update Date: | 09/10/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | RN125386 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | GA |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |