Healthcare Provider Details

I. General information

NPI: 1669777512
Provider Name (Legal Business Name): TRACI LYNN STEVENSON D.O,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI LYNN MOSHER D.O.

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HARTLE CT
NAPA CA
94559-4078
US

IV. Provider business mailing address

1310 CLUB DR STE 109
VALLEJO CA
94592-1189
US

V. Phone/Fax

Practice location:
  • Phone: 707-254-1775
  • Fax: 707-254-1779
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDOS1369
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A9911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: