Provider Demographics
NPI:1821982489
Name:STIDHAM, WANDA RAYE
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:RAYE
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 1:453 OLD KY 11
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41314-9171
Mailing Address - Country:US
Mailing Address - Phone:606-593-6400
Mailing Address - Fax:
Practice Address - Street 1:453 OLD KY 11
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41314-9171
Practice Address - Country:US
Practice Address - Phone:606-593-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-06
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4042301363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care