Provider Demographics
NPI:1023567823
Name:SIDES, STACI JEANNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:JEANNE
Last Name:SIDES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 N LEBANON ST STE 305
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 N MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-9497
Practice Address - Country:US
Practice Address - Phone:765-335-0123
Practice Address - Fax:765-335-0127
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006609A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201403450Medicaid