Provider Demographics
NPI:1023688850
Name:STANCE, AUDRA MARIE (BA, MPA)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:MARIE
Last Name:STANCE
Suffix:
Gender:F
Credentials:BA, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4792
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-0792
Mailing Address - Country:US
Mailing Address - Phone:510-563-9785
Mailing Address - Fax:
Practice Address - Street 1:2310 W STARR ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-3240
Practice Address - Country:US
Practice Address - Phone:510-563-9785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities