Provider Demographics
NPI:1134812324
Name:CANEDO, STEPHANIE BRACAMONTES
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BRACAMONTES
Last Name:CANEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 FAIR ISLE DR APT 70
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-8454
Mailing Address - Country:US
Mailing Address - Phone:760-235-0014
Mailing Address - Fax:
Practice Address - Street 1:5880 FAIR ISLE DR APT 70
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-8454
Practice Address - Country:US
Practice Address - Phone:760-235-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87430225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist