Provider Demographics
NPI:1912600131
Name:STEVENS, CORI LEA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:LEA
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 JACKSON CT
Mailing Address - Street 2:
Mailing Address - City:COTO DE CAZA
Mailing Address - State:CA
Mailing Address - Zip Code:92679-5013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 MAOLI DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-7004
Practice Address - Country:US
Practice Address - Phone:415-202-5041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023382363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health