Provider Demographics
NPI:1942843644
Name:STIDMAN, STEPHANIE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:STIDMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MENDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2723 S 7TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3558
Mailing Address - Country:US
Mailing Address - Phone:812-238-1730
Mailing Address - Fax:
Practice Address - Street 1:2723 S 7TH ST STE A
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3558
Practice Address - Country:US
Practice Address - Phone:812-232-8164
Practice Address - Fax:812-234-6391
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28235757A363L00000X
IN71009684A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300034515Medicaid