Provider Demographics
NPI:1003204959
Name:TERENA STIDHAM
Entity Type:Organization
Organization Name:TERENA STIDHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERENA
Authorized Official - Middle Name:S
Authorized Official - Last Name:STIDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:205-570-8222
Mailing Address - Street 1:2075 COUNTY HIGHWAY 122
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:AL
Mailing Address - Zip Code:35570-8414
Mailing Address - Country:US
Mailing Address - Phone:205-570-8222
Mailing Address - Fax:
Practice Address - Street 1:1050 CONVALESCENT RD
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:AL
Practice Address - Zip Code:35592-4823
Practice Address - Country:US
Practice Address - Phone:205-570-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility