Provider Demographics
NPI:1316767221
Name:PERRILLIAT, STEWART BERNARD II (DMIN)
Entity type:Individual
Prefix:DR
First Name:STEWART
Middle Name:BERNARD
Last Name:PERRILLIAT
Suffix:II
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5416 SHALLOWS PL W
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-5502
Mailing Address - Country:US
Mailing Address - Phone:408-750-4334
Mailing Address - Fax:707-703-5794
Practice Address - Street 1:5416 SHALLOWS PL W
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-5502
Practice Address - Country:US
Practice Address - Phone:408-750-4334
Practice Address - Fax:707-703-5794
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X, 374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner
No172V00000XOther Service ProvidersCommunity Health Worker