Provider Demographics
NPI:1104894971
Name:STIDHAM, DIANA J (CPNP)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:J
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5873 SIGMON WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4847
Mailing Address - Country:US
Mailing Address - Phone:513-829-0692
Mailing Address - Fax:
Practice Address - Street 1:400 E MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229
Practice Address - Country:US
Practice Address - Phone:513-861-7313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-197978363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2357051Medicaid