Basic Information
| Provider Information | |||||||||
| NPI: | 1811624448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNELIO | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIVERA-FLORES | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18726 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902483813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108560800 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 N BRAND BLVD | ||||||||
| Address2: | OFFICE #233 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187221770 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2022 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.