MEDICARE: MRS. CANDACE MARIE STIDOLPH NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner		WY

General Provider Information

NPI Number	:	1699983460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CANDACE MARIE STIDOLPH NP

Provider Business Mailing Address
First Line	:	413 S 21ST ST
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-4323
Country	:	US
Telephone Number	:	307-745-5364
Fax Number	:	307-745-4164

Provider Business Practice Location Address
First Line	:	413 S 21ST ST
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-4323
Country	:	US
Telephone Number	:	307-745-5364
Fax Number	:	307-745-4164

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	04/11/2008

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