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General NPI Number Information
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NPI Number | 1407695182
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Entity Type | Individual
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Provider Name | STACIE ANDERSON AGNP
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Gender | Female
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Dates
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Enumeration Date | 05/22/2024
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Last Update Date | 05/22/2024
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Provider Practice Location Address
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Address Line | 19270 SONOMA HIGHWAY
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City | SONOMA
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State | CA
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Zip | 95476
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Country | US
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Telephone | 707-939-6070
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Fax |
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Provider Business Mailing Address
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Address Line | 911 LAKEVILLE ST # 116
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City | PETALUMA
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State | CA
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Zip | 94952-3329
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Country | US
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Telephone | 509-999-3989
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 95029378
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 95029378
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 95029378
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License Number State | CA
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