Healthcare Provider Details

I. General information

NPI: 1598966459
Provider Name (Legal Business Name): GLENDA SUE STIDHAM IECE CERTIFIED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 MILLER RD
MANCHESTER KY
40962-5714
US

IV. Provider business mailing address

57 MILLER RD
MANCHESTER KY
40962-5714
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-2815
  • Fax: 606-598-0148
Mailing address:
  • Phone: 606-598-2815
  • Fax: 606-598-0148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number01984
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: