Basic Information
| Provider Information | |||||||||
| NPI: | 1225205677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIDWELL | ||||||||
| FirstName: | LELON | ||||||||
| MiddleName: | DARWIN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11219 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761100219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172947444 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11801 SOUTH FWY | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760287021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172939110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 436290 | TX | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
ID Information
| ID | Type | State | Issuer | Description | 436290 | 01 | TX | RN LICENSE | OTHER |