Basic Information
| Provider Information | |||||||||
| NPI: | 1265707533 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIDWELL | ||||||||
| FirstName: | SHERRY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7723 CLEARVIEW CHURCH LN | ||||||||
| Address2: | |||||||||
| City: | LYLES | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370981674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316705520 | ||||||||
| FaxNumber: | 9316705312 | ||||||||
| Practice Location | |||||||||
| Address1: | 7723 CLEARVIEW CHURCH LN | ||||||||
| Address2: | |||||||||
| City: | LYLES | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370981674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316705520 | ||||||||
| FaxNumber: | 9316705312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2012 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 92159 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 16586 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1529543 | 05 | TN | MEDICAID |