Provider Demographics
NPI:1053047084
Name:BRACAMONTE, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BRACAMONTE
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 1:539 N VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93728-3419
Mailing Address - Country:US
Mailing Address - Phone:559-266-9581
Mailing Address - Fax:559-498-0507
Practice Address - Street 1:539 N VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93728-3419
Practice Address - Country:US
Practice Address - Phone:559-266-9581
Practice Address - Fax:559-498-0507
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA221032164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse