Healthcare Provider Details

I. General information

NPI: 1649508763
Provider Name (Legal Business Name): JEREMIAH E STANLEY NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5974 PENTZ RD
PARADISE CA
95969-5509
US

IV. Provider business mailing address

3082 MCMURRAY DR
ANDERSON CA
96007-3544
US

V. Phone/Fax

Practice location:
  • Phone: 530-877-9361
  • Fax:
Mailing address:
  • Phone: 530-365-4420
  • Fax: 530-365-5186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19056
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: