Basic Information
| Provider Information | |||||||||
| NPI: | 1700295284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIDD | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1245 | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291161245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033952200 | ||||||||
| FaxNumber: | 8033952237 | ||||||||
| Practice Location | |||||||||
| Address1: | 1137 COOK RD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291188204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035310970 | ||||||||
| FaxNumber: | 8033952237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2014 | ||||||||
| LastUpdateDate: | 11/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 18998 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 18998 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | GP6199 | 01 | SC | MEDICAID GROUP NUMBER | OTHER |