Provider Demographics
NPI:1124569579
Name:BAKER, STEPHANIE BLAIR (L AC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BLAIR
Last Name:BAKER
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 JACKSON ST APT 24
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-4434
Mailing Address - Country:US
Mailing Address - Phone:510-735-6638
Mailing Address - Fax:
Practice Address - Street 1:1 RIO VISTA AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5320
Practice Address - Country:US
Practice Address - Phone:510-735-6638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-18
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17398171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist