Healthcare Provider Details

I. General information

NPI: 1124730213
Provider Name (Legal Business Name): DYMON MARIE HANES CBD, CPD, CLES, CPE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 12/20/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 N EL DORADO ST
STOCKTON CA
95204-2105
US

IV. Provider business mailing address

4120 N EL DORADO ST
STOCKTON CA
95204-2105
US

V. Phone/Fax

Practice location:
  • Phone: 209-610-6999
  • Fax:
Mailing address:
  • Phone: 209-610-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: