Healthcare Provider Details

I. General information

NPI: 1720284417
Provider Name (Legal Business Name): STACY ELIZABETH HULLEY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 VANDEVER AVE
SAN DIEGO CA
92120-3315
US

IV. Provider business mailing address

4405 VANDEVER AVE UNIT D
SAN DIEGO CA
92120-3315
US

V. Phone/Fax

Practice location:
  • Phone: 619-516-6182
  • Fax:
Mailing address:
  • Phone: 858-254-9465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA106686
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: