Provider Demographics
NPI:1285231258
Name:STIDAM, ALICIA D (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:D
Last Name:STIDAM
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 HOMEPLACE WAY
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-9071
Mailing Address - Country:US
Mailing Address - Phone:606-784-5894
Mailing Address - Fax:
Practice Address - Street 1:245 FLEMINGSBURG RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1015
Practice Address - Country:US
Practice Address - Phone:606-780-5500
Practice Address - Fax:606-783-7281
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015232363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3015232OtherKY MEDICAL LICENSE