Healthcare Provider Details

I. General information

NPI: 1245143130
Provider Name (Legal Business Name): MIA STEPHANIE CROFTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 N RAMONA BLVD
SAN JACINTO CA
92582-2552
US

IV. Provider business mailing address

13608 BAXTER CT
MORENO VALLEY CA
92555-6026
US

V. Phone/Fax

Practice location:
  • Phone: 951-929-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number2B58B11135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: