Healthcare Provider Details

I. General information

NPI: 1679486799
Provider Name (Legal Business Name): STEPHEN WERDER LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 PINE ST
MOUNT SHASTA CA
96067-2137
US

IV. Provider business mailing address

824 PINE ST
MOUNT SHASTA CA
96067-2137
US

V. Phone/Fax

Practice location:
  • Phone: 530-926-4528
  • Fax: 530-926-5070
Mailing address:
  • Phone: 530-926-4528
  • Fax: 530-926-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN758035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: