Healthcare Provider Details

I. General information

NPI: 1063908317
Provider Name (Legal Business Name): STACY TENNILLE WONG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 PARNASSUS AVE
SAN FRANCISCO CA
94143-2206
US

IV. Provider business mailing address

300 PASTEUR DR
STANFORD CA
94305-2200
US

V. Phone/Fax

Practice location:
  • Phone: 415-514-3785
  • Fax: 415-476-9516
Mailing address:
  • Phone: 650-723-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95002044
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number762032
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA95002044
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number730127-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: