Individual
T'JUANIEQUA WIDEMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
AGACNP-BC
Contact information
Practice address
800 E DAWSON ST, TYLER, TX 75701-2036
(903) 593-8441
Mailing address
1309 S AZALEA DR, TYLER, TX 75701-5222
(903) 520-4873
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
1115976
TX
363LG0600X
Gerontology Nurse Practitioner
1115976
TX
Other
Enumeration date
08/22/2023
Last updated
09/22/2023
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