Healthcare Provider Details

I. General information

NPI: 1982957098
Provider Name (Legal Business Name): TAMARA STOGNER RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12140 NEW YORK RANCH RD
JACKSON CA
95642-9407
US

IV. Provider business mailing address

PO BOX 939
ANGELS CAMP CA
95222-0939
US

V. Phone/Fax

Practice location:
  • Phone: 209-257-2400
  • Fax: 209-257-2403
Mailing address:
  • Phone: 209-754-6270
  • Fax: 209-754-6276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number803912
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number803912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: