Provider Demographics
NPI:1750921458
Name:KATISI, STELLA GRACE
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:GRACE
Last Name:KATISI
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 1:326 BROOKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5205
Mailing Address - Country:US
Mailing Address - Phone:770-289-0476
Mailing Address - Fax:
Practice Address - Street 1:490 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-4806
Practice Address - Country:US
Practice Address - Phone:707-964-1848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD026966183500000X
VA0202218297183500000X
CA81824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist