Healthcare Provider Details

I. General information

NPI: 1619703477
Provider Name (Legal Business Name): STEPHANIE HADIMULIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16465 SIERRA LAKES PKWY STE 115
FONTANA CA
92336-1242
US

IV. Provider business mailing address

13256 MURANO AVE
CHINO CA
91710-8116
US

V. Phone/Fax

Practice location:
  • Phone: 909-823-8000
  • Fax: 909-823-8088
Mailing address:
  • Phone: 909-972-5558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68068
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: