Healthcare Provider Details

I. General information

NPI: 1770341638
Provider Name (Legal Business Name): STACEY CHARLENE BEAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W SANTA ANA BLVD STE 1000
SANTA ANA CA
92701-7552
US

IV. Provider business mailing address

200 W SANTA ANA BLVD STE 1000
SANTA ANA CA
92701-7552
US

V. Phone/Fax

Practice location:
  • Phone: 714-480-6641
  • Fax: 714-568-4362
Mailing address:
  • Phone: 714-480-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-PQBHKF
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: