Provider Demographics
NPI:1255050670
Name:STANLEY, ELIJAH JAYLENE
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:JAYLENE
Last Name:STANLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 MAPLEGROVE WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1549
Mailing Address - Country:US
Mailing Address - Phone:916-501-5735
Mailing Address - Fax:
Practice Address - Street 1:899 MAPLEGROVE WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1549
Practice Address - Country:US
Practice Address - Phone:916-501-5735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program