Provider Demographics
NPI:1417569526
Name:STAFFORD, KATHERINE JEANNE (NP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JEANNE
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34952 GAIL AVE
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2830
Mailing Address - Country:US
Mailing Address - Phone:909-917-5504
Mailing Address - Fax:
Practice Address - Street 1:34952 GAIL AVE
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2830
Practice Address - Country:US
Practice Address - Phone:909-917-5504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA489727363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health