Individual
NICOLE LYNN TIDD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1137 COOK RD, ORANGEBURG, SC 29118-8204
(803) 531-0970
(803) 395-2237
Mailing address
PO BOX 1245, ORANGEBURG, SC 29116-1245
(803) 395-2200
(803) 395-2237
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
18998
SC
363LG0600X
Gerontology Nurse Practitioner
18998
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
GP6199
MEDICAID GROUP NUMBER
SC
Enumeration date
08/08/2014
Last updated
11/22/2017
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