Provider Demographics
NPI:1205247053
Name:CAVALLO, STEPHANIE
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:CAVALLO
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 1:950 CODDINGTOWN CTR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-3512
Mailing Address - Country:US
Mailing Address - Phone:707-596-5588
Mailing Address - Fax:707-596-5598
Practice Address - Street 1:950 CODDINGTOWN CTR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-3512
Practice Address - Country:US
Practice Address - Phone:707-596-5588
Practice Address - Fax:707-596-5598
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist