Provider Demographics
NPI:1306338579
Name:TSE, STACY (NP)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:TSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 JOURNEY STE 130
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5330
Mailing Address - Country:US
Mailing Address - Phone:949-360-1069
Mailing Address - Fax:949-360-1069
Practice Address - Street 1:5 JOURNEY STE 130
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5330
Practice Address - Country:US
Practice Address - Phone:949-360-1069
Practice Address - Fax:949-389-8968
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008899363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95008899OtherNURSE PRACTITIONER