Healthcare Provider Details

I. General information

NPI: 1336840016
Provider Name (Legal Business Name): STACY LYNN NILSEN MSN, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 FROST ST
SAN DIEGO CA
92123-2701
US

IV. Provider business mailing address

7901 FROST ST
SAN DIEGO CA
92123-2701
US

V. Phone/Fax

Practice location:
  • Phone: 858-472-5112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number3418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: