Provider Demographics
NPI:1407695182
Name:ANDERSON, STACIE (AGNP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 LAKEVILLE ST # 116
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3329
Mailing Address - Country:US
Mailing Address - Phone:509-999-3989
Mailing Address - Fax:
Practice Address - Street 1:19270 SONOMA HIGHWAY
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476
Practice Address - Country:US
Practice Address - Phone:707-939-6070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029378363L00000X, 363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care