Individual
TIMOTHY JAMES STACY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ACNP
Contact information
Practice address
4955 VAN NUYS BLVD, SUITE 502, SHERMAN OAKS, CA 91403-1801
(818) 325-0200
(818) 325-0210
Mailing address
5268 HUCKLEBERRY OAK STREET, SIMI VALLEY, CA 93063
(805) 208-0434
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
Primary
15005
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2571636
—
CA
01
—
B1180Z
MEDICARE PTAN
CA
05
—
NP0150050
—
CA
Enumeration date
06/16/2005
Last updated
02/23/2010
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