Healthcare Provider Details

I. General information

NPI: 1821724113
Provider Name (Legal Business Name): STACEY LIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 COTTONWOOD CREEK TRL STE 410
CEDAR PARK TX
78613-2688
US

IV. Provider business mailing address

133 NIGHT BLOOM PATH
LIBERTY HILL TX
78642-2365
US

V. Phone/Fax

Practice location:
  • Phone: 760-207-8640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1053491
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number1053491
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: