Healthcare Provider Details

I. General information

NPI: 1356125959
Provider Name (Legal Business Name): STACY LANELL TIDD MSN/ED, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 LAS TABLAS RD STE B4
TEMPLETON CA
93465-9703
US

IV. Provider business mailing address

959 LAS TABLAS RD STE B4
TEMPLETON CA
93465-9703
US

V. Phone/Fax

Practice location:
  • Phone: 805-423-9947
  • Fax: 801-434-1107
Mailing address:
  • Phone: 805-423-9947
  • Fax: 805-434-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95026799
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: