Provider Demographics
NPI:1922269307
Name:PRIDEMORE, STEPHANIE K (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:K
Last Name:PRIDEMORE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1618 HARRODSBURG RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3706
Mailing Address - Country:US
Mailing Address - Phone:859-288-5004
Mailing Address - Fax:859-288-5007
Practice Address - Street 1:1618 HARRODSBURG RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3706
Practice Address - Country:US
Practice Address - Phone:859-288-5004
Practice Address - Fax:859-288-5007
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA6022083X0100X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine