Healthcare Provider Details

I. General information

NPI: 1619277225
Provider Name (Legal Business Name): STACEY CHARLENE MCVICKER OQP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CROWN POINT CIR STE 120
GRASS VALLEY CA
95945-9561
US

IV. Provider business mailing address

995 HELLING WAY
NEVADA CITY CA
95959-8619
US

V. Phone/Fax

Practice location:
  • Phone: 530-265-7222
  • Fax:
Mailing address:
  • Phone: 530-265-7222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: