Provider Demographics
NPI:1083506026
Name:TICKEMYER, STEPHANIE RENEE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:TICKEMYER
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 1:1154 FAIRWAY OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6411
Mailing Address - Country:US
Mailing Address - Phone:951-312-1688
Mailing Address - Fax:
Practice Address - Street 1:7707 AUSTIN RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95215-8312
Practice Address - Country:US
Practice Address - Phone:951-312-1688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-16
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program