MEDICARE: ELIJAH JAYLENE STANLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1255050670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIJAH JAYLENE STANLEY

Provider Business Mailing Address
First Line	:	899 MAPLEGROVE WAY
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-1549
Country	:	US
Telephone Number	:	916-501-5735
Fax Number	:

Provider Business Practice Location Address
First Line	:	899 MAPLEGROVE WAY
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-1549
Country	:	US
Telephone Number	:	916-501-5735
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2022
Last Update Date	:	08/29/2022

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