Provider Demographics
NPI:1548519739
Name:TIDWELL, ANTONIA (RDMS, RVT, RDCS, RTR)
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:RDMS, RVT, RDCS, RTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 SAVANNAH RDG
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37127-8331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:323 SAVANNAH RDG
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37127-8331
Practice Address - Country:US
Practice Address - Phone:615-708-3179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-03
Last Update Date:2012-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN115198246XS1301X, 2471S1302X, 2471V0105X
TN3104582471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography