Provider Demographics
NPI:1609318278
Name:SIDBERRY, STACIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:SIDBERRY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:SIDBERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:4128 ODESSA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80249-8002
Mailing Address - Country:US
Mailing Address - Phone:720-621-1544
Mailing Address - Fax:
Practice Address - Street 1:4128 ODESSA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80249-8002
Practice Address - Country:US
Practice Address - Phone:720-621-1544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-13
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0167958163W00000X
CO0996414-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse