1770729998 NPI number — ANGELA KIM TIDWELL SLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770729998 NPI number — ANGELA KIM TIDWELL SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIDWELL
Provider First Name:
ANGELA
Provider Middle Name:
KIM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HESTLE
Provider Other First Name:
KIM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1770729998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 PECAN HILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39056-5233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-862-9265
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
733 N. FLAG CHAPEL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-922-5530
Provider Business Practice Location Address Fax Number:
601-922-5534
Provider Enumeration Date:
12/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  S2357 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: S2357 . This is a "MS STATE BOARD OF HEALTH" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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