Basic Information
| Provider Information | |||||||||
| NPI: | 1477091122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDWELL | ||||||||
| FirstName: | MELANI | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3572 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383033572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316681853 | ||||||||
| FaxNumber: | 7316647731 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 TUCKER STREET | ||||||||
| Address2: | STE 2 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316681853 | ||||||||
| FaxNumber: | 7316647731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2017 | ||||||||
| LastUpdateDate: | 02/02/2017 | ||||||||
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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 | 363L00000X | 121210 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 121210 | 01 | TN | RN | OTHER |