Provider Demographics
NPI:1053927608
Name:HARGROVE, STEPHENIE (NP)
Entity type:Individual
Prefix:MS
First Name:STEPHENIE
Middle Name:
Last Name:HARGROVE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19947 MOUNTAIN MDW N
Mailing Address - Street 2:
Mailing Address - City:HIDDEN VALLEY LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95467-8546
Mailing Address - Country:US
Mailing Address - Phone:615-693-0403
Mailing Address - Fax:
Practice Address - Street 1:15630 18TH AVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9336
Practice Address - Country:US
Practice Address - Phone:707-994-6486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012363363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily