Provider Demographics
NPI:1962107342
Name:RICHARDSON, STEPHANIE KUMALAO
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KUMALAO
Last Name:RICHARDSON
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 1:15027 MANNING ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-1033
Mailing Address - Country:US
Mailing Address - Phone:818-259-9107
Mailing Address - Fax:
Practice Address - Street 1:15027 MANNING ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-1033
Practice Address - Country:US
Practice Address - Phone:818-259-9107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA365530050310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility