Provider Demographics
NPI:1396332375
Name:SIDWELL, BARRY (FNP)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:SIDWELL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 LAKEWOOD DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6217
Mailing Address - Country:US
Mailing Address - Phone:731-343-2486
Mailing Address - Fax:
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3923
Practice Address - Country:US
Practice Address - Phone:731-343-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28237363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily