Provider Demographics
NPI:1710287263
Name:SIDEBOTHAM, STACIE A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:A
Last Name:SIDEBOTHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 OWEN DR
Mailing Address - Street 2:STE 201
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3490
Mailing Address - Country:US
Mailing Address - Phone:910-323-9111
Mailing Address - Fax:910-484-2535
Practice Address - Street 1:405 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3411
Practice Address - Country:US
Practice Address - Phone:910-323-3183
Practice Address - Fax:910-323-5488
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily