Basic Information
| Provider Information | |||||||||
| NPI: | 1265429518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICKERING | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 LENNON LN | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945985910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259326330 | ||||||||
| FaxNumber: | 9259320139 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 LENNON LN | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945985910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259326330 | ||||||||
| FaxNumber: | 9259320139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP9162428 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 208800000X | ARNP9162428 | FL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3066398-00 | 05 | FL | MEDICAID |