Healthcare Provider Details

I. General information

NPI: 1831660182
Provider Name (Legal Business Name): STACY DRUIVENGA RCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 EUREKA RD
ROSEVILLE CA
95661-3027
US

IV. Provider business mailing address

1617 RED SQUIRREL ST
ROSEVILLE CA
95747-4637
US

V. Phone/Fax

Practice location:
  • Phone: 916-474-7777
  • Fax:
Mailing address:
  • Phone: 916-806-7094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2278P3900X
TaxonomyNeonatal/Pediatric Certified Respiratory Therapist
License Number25030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: