Provider Demographics
NPI:1144867409
Name:TIDWELL -SHOEMAKER, MARILYN LORETTA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:LORETTA
Last Name:TIDWELL -SHOEMAKER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:233 WINTON BLOUNT LOOP
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3507
Mailing Address - Country:US
Mailing Address - Phone:334-239-2622
Mailing Address - Fax:
Practice Address - Street 1:233 WINTON BLOUNT LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3507
Practice Address - Country:US
Practice Address - Phone:334-350-5648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013184363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health