Provider Demographics
NPI:1700378049
Name:STIDHAM, DAVID E (FPMHNP)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:E
Last Name:STIDHAM
Suffix:
Gender:M
Credentials:FPMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 N OAK STREET EXT STE C
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5910
Mailing Address - Country:US
Mailing Address - Phone:229-896-4559
Mailing Address - Fax:229-896-8367
Practice Address - Street 1:1905 S HUTCHINSON AVE
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-5246
Practice Address - Country:US
Practice Address - Phone:229-896-4559
Practice Address - Fax:229-896-8367
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN139536363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily