Provider Demographics
NPI:1902529571
Name:STIDHAM, VANESSA NICOLE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:NICOLE
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45680-9683
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5187 US ROUTE 60 STE 13
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2076
Practice Address - Country:US
Practice Address - Phone:304-733-5010
Practice Address - Fax:304-733-5024
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV72807163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse