Provider Demographics
NPI:1053647727
Name:TIDD, ANITA K (LPN)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:K
Last Name:TIDD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:PATTEN
Mailing Address - State:ME
Mailing Address - Zip Code:04765-0500
Mailing Address - Country:US
Mailing Address - Phone:207-528-2285
Mailing Address - Fax:207-528-2280
Practice Address - Street 1:30 HOULTON RD
Practice Address - Street 2:
Practice Address - City:PATTEN
Practice Address - State:ME
Practice Address - Zip Code:04765-0500
Practice Address - Country:US
Practice Address - Phone:207-528-2285
Practice Address - Fax:207-528-2280
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEP010477164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse