Healthcare Provider Details

I. General information

NPI: 1184181620
Provider Name (Legal Business Name): STEPHANIE BURDESHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4189 SIERRA MADRE AVE
CLOVIS CA
93619-5239
US

IV. Provider business mailing address

4189 SIERRA MADRE AVE
CLOVIS CA
93619-5239
US

V. Phone/Fax

Practice location:
  • Phone: 850-557-3101
  • Fax:
Mailing address:
  • Phone: 559-453-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number692429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: