MEDICARE: MRS. TERENA S STIDHAM CFNP

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	R857697	MS
2	363LF0000X	Family Nurse Practitioner	1-081469	AL
3	363LF0000X	Family Nurse Practitioner	2005009897-22	AL

General Provider Information

NPI Number	:	1861443087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERENA S STIDHAM CFNP

Provider Business Mailing Address
First Line	:	123 MAIN ST N
Second Line	:
City	:	AMORY
State	:	MS
Zip	:	38821-3416
Country	:	US
Telephone Number	:	662-256-7112
Fax Number	:	662-256-7116

Provider Business Practice Location Address
First Line	:	65345 HWY 17
Second Line	:
City	:	DETROIT
State	:	AL
Zip	:	35552
Country	:	US
Telephone Number	:	205-273-4056
Fax Number	:	205-273-4058

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	09/24/2012

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