Provider Demographics
NPI:1982076063
Name:NUSSENBAUM-LAUREN, STACY (LAC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:NUSSENBAUM-LAUREN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:LAUREN-KON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:1721 DELOZ AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-4615
Mailing Address - Country:US
Mailing Address - Phone:323-459-2000
Mailing Address - Fax:
Practice Address - Street 1:4446 AMBROSE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2115
Practice Address - Country:US
Practice Address - Phone:323-459-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16756171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist