Healthcare Provider Details

I. General information

NPI: 1639033756
Provider Name (Legal Business Name): STACIE I. SANTANA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27555 YNEZ RD STE 300
TEMECULA CA
92591-4678
US

IV. Provider business mailing address

107 LIGHTHOUSE CT
SAN JACINTO CA
92583-6537
US

V. Phone/Fax

Practice location:
  • Phone: 951-466-3196
  • Fax:
Mailing address:
  • Phone: 951-513-5996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: