Provider Demographics
NPI:1417146655
Name:NORMAN, STACY (PA)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:NORMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 SAN MIGUEL DR
Mailing Address - Street 2:STE 603
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7832
Mailing Address - Country:US
Mailing Address - Phone:949-707-5734
Mailing Address - Fax:949-707-1924
Practice Address - Street 1:22972 MOULTON PKWY STE 106
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1219
Practice Address - Country:US
Practice Address - Phone:949-707-5734
Practice Address - Fax:949-707-1924
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA17505174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist