Provider Demographics
NPI:1659338366
Name:NELSON-HICKS, STACE LEE (LAC)
Entity Type:Individual
Prefix:
First Name:STACE
Middle Name:LEE
Last Name:NELSON-HICKS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:53 LIVE OAK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-3313
Mailing Address - Country:US
Mailing Address - Phone:805-643-7014
Mailing Address - Fax:
Practice Address - Street 1:1732 PALMA DR
Practice Address - Street 2:104
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5796
Practice Address - Country:US
Practice Address - Phone:805-279-1119
Practice Address - Fax:805-642-6524
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7329171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist