Provider Demographics
NPI:1609206523
Name:GUILLEN, STACIA (FNP-C)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:GUILLEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 COVENTRY WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-6701
Mailing Address - Country:US
Mailing Address - Phone:714-642-6149
Mailing Address - Fax:
Practice Address - Street 1:239 HURFFVILLE CROSSKEYS RD
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-4002
Practice Address - Country:US
Practice Address - Phone:856-341-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA788745163W00000X
CA23757363LF0000X
NJ26NJ00527600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse