Provider Demographics
NPI:1053161026
Name:TIDWELL, SHARON
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14737 N GALLATIN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKPARK
Mailing Address - State:OH
Mailing Address - Zip Code:44142-2424
Mailing Address - Country:US
Mailing Address - Phone:216-317-0489
Mailing Address - Fax:
Practice Address - Street 1:14737 N GALLATIN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKPARK
Practice Address - State:OH
Practice Address - Zip Code:44142-2424
Practice Address - Country:US
Practice Address - Phone:216-317-0489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider