Provider Demographics
NPI:1831660182
Name:DRUIVENGA, STACY (RCP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:DRUIVENGA
Suffix:
Gender:F
Credentials:RCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 RED SQUIRREL ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-4637
Mailing Address - Country:US
Mailing Address - Phone:916-806-7094
Mailing Address - Fax:
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:916-474-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250302278P3900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedNeonatal/Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25030OtherRESPIRATORY