Basic Information
| Provider Information | |||||||||
| NPI: | 1083750590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDNER | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY | ||||||||
| Address2: | 290 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022175134 | ||||||||
| FaxNumber: | 5022175056 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 STOUT DRIVE | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394225 | ||||||||
| FaxNumber: | 4234394560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 01/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 23528 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 23528 | 01 | TN | LICENSE | OTHER |