Healthcare Provider Details

I. General information

NPI: 1922340546
Provider Name (Legal Business Name): ANTOINETTE SUSAN STEVENS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3744 BLUFF PL
SAN PEDRO CA
90731-7006
US

IV. Provider business mailing address

3744 BLUFF PL
SAN PEDRO CA
90731-7006
US

V. Phone/Fax

Practice location:
  • Phone: 424-772-1649
  • Fax:
Mailing address:
  • Phone: 424-772-1649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number235258
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number235258
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number235258
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: