Provider Demographics
NPI:1558836510
Name:HALDERMAN, STACY (FNP-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:HALDERMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:CAISIP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:2250 S MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-2538
Mailing Address - Country:US
Mailing Address - Phone:951-737-1454
Mailing Address - Fax:
Practice Address - Street 1:2250 S MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882
Practice Address - Country:US
Practice Address - Phone:951-737-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010080363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily