Provider Demographics
NPI:1285285387
Name:GRISWOLD, STEPHANIE VALESKA
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:VALESKA
Last Name:GRISWOLD
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 1:31935 VIA CORDOBA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-1067
Mailing Address - Country:US
Mailing Address - Phone:262-689-8182
Mailing Address - Fax:
Practice Address - Street 1:31935 VIA CORDOBA
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-1067
Practice Address - Country:US
Practice Address - Phone:262-689-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY3748668OtherDRIVER LICENSE