Individual
STACY RENEE TIDWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
4618 WILLOW RIDGE WAY, ROGERS, AR 72758-8089
(479) 587-1700
Mailing address
4618 WILLOW RIDGE WAY, ROGERS, AR 72758-8089
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
A003421
AR
363LW0102X
Women's Health Nurse Practitioner
Primary
A003421
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1265746820
—
MO
05
—
184226758
—
AR
05
—
200301950A
—
OK
Enumeration date
08/05/2010
Last updated
04/04/2023
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