Basic Information
| Provider Information | |||||||||
| NPI: | 1154792893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOUDEMAYER | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976308 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3551A RUTHERFORD RD | ||||||||
| Address2: | |||||||||
| City: | TAYLORS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296872195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645224750 | ||||||||
| FaxNumber: | 8645224755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2015 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 19744 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP3619 | 05 | SC | MEDICAID |