Provider Demographics
NPI:1801237888
Name:PHILLIPS, STACEY ANN MARIE (LVN)
Entity type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:ANN MARIE
Last Name:PHILLIPS
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 1:40700 CALIFORNIA OAKS RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562
Mailing Address - Country:US
Mailing Address - Phone:951-894-5072
Mailing Address - Fax:951-894-7324
Practice Address - Street 1:40700 CALIFORNIA OAKS RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5795
Practice Address - Country:US
Practice Address - Phone:951-894-5072
Practice Address - Fax:951-894-7324
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA263312164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330652055Medicaid