Provider Demographics
NPI:1962089508
Name:DESLATE, STEPHANIE (NP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DESLATE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12675 LA MIRADA BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-2235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12675 LA MIRADA BLVD STE 220
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-2235
Practice Address - Country:US
Practice Address - Phone:562-967-2273
Practice Address - Fax:562-967-2911
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95015073363LF0000X
CA95114124163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse