Basic Information
| Provider Information | |||||||||
| NPI: | 1700256062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STIDHAM | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 N SENATE BLVD STE 3300 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179231787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2015 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71005926A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 28191983A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201333360 | 05 | IN | MEDICAID |