Provider Demographics
NPI:1407470396
Name:PRIDEMORE, AMY STARLING
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:STARLING
Last Name:PRIDEMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GROVE HILL
Mailing Address - State:AL
Mailing Address - Zip Code:36451-3231
Mailing Address - Country:US
Mailing Address - Phone:251-275-3173
Mailing Address - Fax:
Practice Address - Street 1:295 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:GROVE HILL
Practice Address - State:AL
Practice Address - Zip Code:36451-3231
Practice Address - Country:US
Practice Address - Phone:251-275-3173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-123553363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily