Provider Demographics
NPI:1780854760
Name:PETERSON, STEPHANIE ANN (PMHNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:BIXBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:859 WASHINGTON ST # 203
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-2704
Mailing Address - Country:US
Mailing Address - Phone:530-262-7025
Mailing Address - Fax:
Practice Address - Street 1:21449 ROUGHOUT RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-8209
Practice Address - Country:US
Practice Address - Phone:530-262-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020435363LP0808X
CA716439163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health