Healthcare Provider Details

I. General information

NPI: 1629110655
Provider Name (Legal Business Name): STACY ANN VENCILL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. STACY ANN HECKMAN

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4870 BARRANCA PKWY 350
IRVINE CA
92604-4709
US

IV. Provider business mailing address

PO BOX 15243
NEWPORT BEACH CA
92659-5243
US

V. Phone/Fax

Practice location:
  • Phone: 949-451-6060
  • Fax: 949-451-6070
Mailing address:
  • Phone: 949-574-4600
  • Fax: 949-574-4680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA18107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: