Provider Demographics
NPI:1053447870
Name:LA JEUNESSE, STACIE (CPNP)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:LA JEUNESSE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 OLD TUNNEL RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-8524
Mailing Address - Country:US
Mailing Address - Phone:530-274-9762
Mailing Address - Fax:530-273-7255
Practice Address - Street 1:844 OLD TUNNEL RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-8524
Practice Address - Country:US
Practice Address - Phone:530-274-9762
Practice Address - Fax:530-273-7255
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC300243363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics