Provider Demographics
NPI:1316947260
Name:TIDMAN, LEE ANN (CNP)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:TIDMAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RIVERSTONE VIS
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6648
Mailing Address - Country:US
Mailing Address - Phone:706-632-4400
Mailing Address - Fax:706-632-4404
Practice Address - Street 1:101 RIVERSTONE VIS
Practice Address - Street 2:SUITE 205
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6648
Practice Address - Country:US
Practice Address - Phone:706-632-4400
Practice Address - Fax:706-632-4404
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN043489363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000498165FMedicaid
B57148Medicare UPIN
GA000498165FMedicaid