Healthcare Provider Details

I. General information

NPI: 1235824350
Provider Name (Legal Business Name): TRACY M STICE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 403
ORANGE CA
92868-3855
US

IV. Provider business mailing address

17811 ROMELLE AVE
SANTA ANA CA
92705-1137
US

V. Phone/Fax

Practice location:
  • Phone: 714-997-7140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number429738
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: