Provider Demographics
NPI:1578664652
Name:STIDHAM, DOROTHY ELLEN (CRNP)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ELLEN
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2282
Mailing Address - Street 2:206 BEXAR AVE. E SUITE 2
Mailing Address - City:HAMILTON
Mailing Address - State:AL
Mailing Address - Zip Code:35570-2282
Mailing Address - Country:US
Mailing Address - Phone:205-952-9603
Mailing Address - Fax:205-952-9661
Practice Address - Street 1:1911 MILITARY ST S
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:AL
Practice Address - Zip Code:35570-6611
Practice Address - Country:US
Practice Address - Phone:205-952-9603
Practice Address - Fax:205-952-9661
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1061751363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051552982Medicaid
AL51552982Medicare UPIN
AL051552982Medicaid