Provider Demographics
NPI:1861443087
Name:STIDHAM, TERENA S (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:TERENA
Middle Name:S
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-3416
Mailing Address - Country:US
Mailing Address - Phone:662-256-7112
Mailing Address - Fax:662-256-7116
Practice Address - Street 1:65345 HWY 17
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:AL
Practice Address - Zip Code:35552
Practice Address - Country:US
Practice Address - Phone:205-273-4056
Practice Address - Fax:205-273-4058
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857697363LF0000X
AL1-081469363LF0000X
AL2005009897-22363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily