MEDICARE: STELLA GRACE KATISI

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	183500000X	Pharmacist	026966	MD
2	183500000X	Pharmacist	0202218297	VA
3	183500000X	Pharmacist	81824	CA

General Provider Information

NPI Number	:	1750921458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STELLA GRACE KATISI

Provider Business Mailing Address
First Line	:	326 BROOKWOOD AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-5205
Country	:	US
Telephone Number	:	770-289-0476
Fax Number	:

Provider Business Practice Location Address
First Line	:	490 S MAIN ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-4806
Country	:	US
Telephone Number	:	707-964-1848
Fax Number	:

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

Provider Enumeration Date	:	01/09/2020
Last Update Date	:	01/09/2020

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Directions to “ STELLA GRACE KATISI ” Practice Location

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