Healthcare Provider Details

I. General information

NPI: 1285890616
Provider Name (Legal Business Name): STASIA TELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 SOQUEL AVE
SANTA CRUZ CA
95062-1323
US

IV. Provider business mailing address

2350 W EL CAMINO REAL FL 2
MOUNTAIN VIEW CA
94040-6203
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-5537
  • Fax:
Mailing address:
  • Phone: 650-934-3546
  • Fax: 650-691-6193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18393
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: