Provider Demographics
NPI:1245014646
Name:CERVERIZZO-SANFORD, STEPHANI MARIE
Entity type:Individual
Prefix:
First Name:STEPHANI
Middle Name:MARIE
Last Name:CERVERIZZO-SANFORD
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 1:771 W BLAINE ST STE D
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3940
Mailing Address - Country:US
Mailing Address - Phone:951-955-2233
Mailing Address - Fax:
Practice Address - Street 1:771 W BLAINE ST STE D
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3940
Practice Address - Country:US
Practice Address - Phone:951-955-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSS-YNQAJE175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker