Provider Demographics
NPI:1457356479
Name:STACY, TIMOTHY JAMES (ACNP)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:STACY
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5268 HUCKLEBERRY OAK STREET
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063
Mailing Address - Country:US
Mailing Address - Phone:805-208-0434
Mailing Address - Fax:
Practice Address - Street 1:4955 VAN NUYS BLVD
Practice Address - Street 2:SUITE 502
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1801
Practice Address - Country:US
Practice Address - Phone:818-325-0200
Practice Address - Fax:818-325-0210
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15005363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP0150050Medicaid
CA2571636Medicaid
CAB1180ZOtherMEDICARE PTAN
CA2571636Medicaid
CANP15005Medicare ID - Type UnspecifiedMEDICARE NUMBER