Individual
LILLIE TIDWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2332 ISLE ROYALE CT SE, WINTER HAVEN, FL 33880-4325
(863) 595-6212
Mailing address
2332 ISLE ROYALE CT SE, WINTER HAVEN, FL 33880-4325
(863) 595-6212
Taxonomy
Speciality
Code
Description
License number
State
376J00000X
Homemaker
Primary
104129000
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
104129000
—
FL
05
—
104851900
—
FL
Enumeration date
11/20/2019
Last updated
11/03/2022
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