Healthcare Provider Details

I. General information

NPI: 1003509241
Provider Name (Legal Business Name): STEPHANIE PUKINI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE MARTON

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2592 N SANTIAGO BLVD
ORANGE CA
92867-1862
US

IV. Provider business mailing address

2592 N SANTIAGO BLVD
ORANGE CA
92867-1862
US

V. Phone/Fax

Practice location:
  • Phone: 855-434-7763
  • Fax:
Mailing address:
  • Phone: 855-434-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95000480
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: