Healthcare Provider Details

I. General information

NPI: 1124536073
Provider Name (Legal Business Name): SHA'TARA L STEVENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E MOUNTAIN VIEW ST STE 101102
BARSTOW CA
92311-2814
US

IV. Provider business mailing address

PO BOX 1927
BIG BEAR LAKE CA
92315-1927
US

V. Phone/Fax

Practice location:
  • Phone: 760-256-7279
  • Fax:
Mailing address:
  • Phone: 909-866-3228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: