Provider Demographics
NPI:1265717565
Name:BEDOLLA, STEPHANIE LISETTE (NP-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LISETTE
Last Name:BEDOLLA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 511250
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-7805
Mailing Address - Country:US
Mailing Address - Phone:510-929-1400
Mailing Address - Fax:510-929-1414
Practice Address - Street 1:16977 HEALDSBURG AVE
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3261
Practice Address - Country:US
Practice Address - Phone:510-929-1400
Practice Address - Fax:510-929-1414
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2275566363LA2200X
RINPP37728363LA2200X
CA95002835363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11009205/AMedicaid
RISB90061Medicaid
RISB90061Medicaid