Basic Information
| Provider Information | |||||||||
| NPI: | 1427521814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIDRICK | ||||||||
| FirstName: | KRISTIE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W WHITE RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473034988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776685621 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 WALTER SCHOLER DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479096303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2019 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | PENDING | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 28210200A | IN | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | IN | ANTHEM PIN NUMBER | OTHER | PENDING | 05 | IN | MEDICAID |