Provider Demographics
NPI:1104074822
Name:TIDWELL, KELLI D (FNP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:D
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 DOWELL SPRINGS BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909
Mailing Address - Country:US
Mailing Address - Phone:865-637-8812
Mailing Address - Fax:865-637-8865
Practice Address - Street 1:1450 DOWELL SPRINGS BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909
Practice Address - Country:US
Practice Address - Phone:865-637-8812
Practice Address - Fax:865-637-8865
Is Sole Proprietor?:No
Enumeration Date:2008-09-06
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000007947363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ005786Medicaid