Provider Demographics
NPI:1467028209
Name:DAVIDSON, STACY (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:BROICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2432 MEADOWLARK CIR
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-4628
Mailing Address - Country:US
Mailing Address - Phone:507-360-9625
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003179363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics