Provider Demographics
NPI:1336900398
Name:ENRIQUEZ, MA STEPHANIE NARES (ADMINISTRATOR, OWNER)
Entity Type:Individual
Prefix:
First Name:MA STEPHANIE
Middle Name:NARES
Last Name:ENRIQUEZ
Suffix:
Gender:F
Credentials:ADMINISTRATOR, OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 OAKMONT PL
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-5114
Mailing Address - Country:US
Mailing Address - Phone:925-967-8626
Mailing Address - Fax:
Practice Address - Street 1:1408 OAKMONT PL
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-5114
Practice Address - Country:US
Practice Address - Phone:925-967-8626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA079201037310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility