Provider Demographics
NPI:1679773923
Name:TIDLER, ELIZABETH MARY (RN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY
Last Name:TIDLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 RAMBLE HILL LN
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545
Mailing Address - Country:US
Mailing Address - Phone:845-677-9500
Mailing Address - Fax:
Practice Address - Street 1:55 RAMBLE HILL LN
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545
Practice Address - Country:US
Practice Address - Phone:845-677-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY505377-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY505377-1Medicaid