Provider Demographics
NPI:1568791978
Name:SANBORN, STACIE (NP)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:
Last Name:SANBORN
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-5335
Mailing Address - Country:US
Mailing Address - Phone:530-383-4958
Mailing Address - Fax:
Practice Address - Street 1:520 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-5335
Practice Address - Country:US
Practice Address - Phone:530-383-4958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3247364SP0200X
CA11031363LP0808X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics