Provider Demographics
NPI:1043753957
Name:TAI, STEPHANIE MICHELLE (FNP, MSN, RN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:TAI
Suffix:
Gender:F
Credentials:FNP, MSN, RN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MICHELLE
Other - Last Name:GUEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-204-5514
Mailing Address - Fax:510-204-5515
Practice Address - Street 1:2500 MILVIA ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2636
Practice Address - Country:US
Practice Address - Phone:510-204-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-24
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005891363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95005891OtherSTATE MEDICAL LICENSE