Provider Demographics
NPI:1497456719
Name:STIDHAM, KALI (NP)
Entity Type:Individual
Prefix:
First Name:KALI
Middle Name:
Last Name:STIDHAM
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 1:343 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-1454
Mailing Address - Country:US
Mailing Address - Phone:419-309-7705
Mailing Address - Fax:
Practice Address - Street 1:3020 N MCCORD RD STE 100
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-1701
Practice Address - Country:US
Practice Address - Phone:419-725-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0033281363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily