Provider Demographics
NPI:1336604040
Name:MERRITT, STACEY (LVN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MERRITT
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 N OAK KNOLL AVE UNIT 27
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1876
Mailing Address - Country:US
Mailing Address - Phone:352-219-4903
Mailing Address - Fax:
Practice Address - Street 1:844 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1325
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:310-314-1928
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA694992101YA0400X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)