Provider Demographics
NPI:1699983460
Name:STIDOLPH, CANDACE MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:MARIE
Last Name:STIDOLPH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 S 21ST ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-4323
Mailing Address - Country:US
Mailing Address - Phone:307-745-5364
Mailing Address - Fax:307-745-4164
Practice Address - Street 1:413 S 21ST ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4323
Practice Address - Country:US
Practice Address - Phone:307-745-5364
Practice Address - Fax:307-745-4164
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily