MEDICARE: TIMOTHY JAMES STACY ACNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	15005	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	B1180Z	OTHER	CA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457356479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY JAMES STACY ACNP

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

Provider Business Practice Location Address
First Line	:	4955 VAN NUYS BLVD
Second Line	:	SUITE 502
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91403-1801
Country	:	US
Telephone Number	:	818-325-0200
Fax Number	:	818-325-0210

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	02/23/2010

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