Provider Demographics
NPI:1053926774
Name:MANOHARA, STACEY ELIZABETH (RN)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ELIZABETH
Last Name:MANOHARA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12107 ASHLYN DR
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-8401
Mailing Address - Country:US
Mailing Address - Phone:661-472-8444
Mailing Address - Fax:
Practice Address - Street 1:4580 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-1104
Practice Address - Country:US
Practice Address - Phone:661-327-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95066883163W00000X
CA95016205363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse