Provider Demographics
NPI:1639672017
Name:WILKINSON, STEPHANIE NADINE (OT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NADINE
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:N
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1636 RIVENDEL DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-0716
Mailing Address - Country:US
Mailing Address - Phone:951-335-6993
Mailing Address - Fax:
Practice Address - Street 1:3688 NYE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1818
Practice Address - Country:US
Practice Address - Phone:951-335-6993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5013225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist