1609318278 NPI number — STACIE SIDBERRY NURSE PRACTITIONER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609318278 NPI number — STACIE SIDBERRY NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIDBERRY
Provider First Name:
STACIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIDBERRY
Provider Other First Name:
STACIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1609318278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4128 ODESSA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80249-8002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-621-1544
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4128 ODESSA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80249-8002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-621-1544
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  0167958 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 0996414-NP , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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