Provider Demographics
NPI:1629110655
Name:VENCILL, STACY ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANN
Last Name:VENCILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:HECKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 15243
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-5243
Mailing Address - Country:US
Mailing Address - Phone:949-574-4600
Mailing Address - Fax:949-574-4680
Practice Address - Street 1:4870 BARRANCA PKWY
Practice Address - Street 2:350
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4709
Practice Address - Country:US
Practice Address - Phone:949-451-6060
Practice Address - Fax:949-451-6070
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18107363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA18107AMedicare PIN