Provider Demographics
NPI:1982250833
Name:RICHARDSON, STEPHANIE MARIE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5539 HOLLISTER RD
Mailing Address - Street 2:
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371-7517
Mailing Address - Country:US
Mailing Address - Phone:760-220-6022
Mailing Address - Fax:
Practice Address - Street 1:12677 HESPERIA RD STE 130
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7735
Practice Address - Country:US
Practice Address - Phone:760-241-7763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily