1457356479 NPI number — TIMOTHY JAMES STACY ACNP

Table of content: TIMOTHY JAMES STACY ACNP (NPI 1457356479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457356479 NPI number — TIMOTHY JAMES STACY ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACY
Provider First Name:
TIMOTHY
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457356479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5268 HUCKLEBERRY OAK STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIMI VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-208-0434
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4955 VAN NUYS BLVD
Provider Second Line Business Practice Location Address:
SUITE 502
Provider Business Practice Location Address City Name:
SHERMAN OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91403-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-325-0200
Provider Business Practice Location Address Fax Number:
818-325-0210
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  15005 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP0150050 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2571636 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: B1180Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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