Provider Demographics
NPI:1104308345
Name:WHATLEY, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WHATLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:LAMBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9664 LAKE NATOMA DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-5052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2390 E BIDWELL ST STE 400
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-983-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT34053-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist