Provider Demographics
NPI:1699800383
Name:TIDWELL, BRENDA LOUISE (FNP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LOUISE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17026 IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-9112
Mailing Address - Country:US
Mailing Address - Phone:559-583-2254
Mailing Address - Fax:559-583-2291
Practice Address - Street 1:1025 N DOUTY ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3722
Practice Address - Country:US
Practice Address - Phone:559-583-2254
Practice Address - Fax:559-583-2291
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10740363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner