Provider Demographics
NPI:1144719527
Name:PETERSEN, STACY ANNE (FNP-C)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANNE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26791 ALISO CREEK RD
Mailing Address - Street 2:1018
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677
Mailing Address - Country:US
Mailing Address - Phone:949-991-4172
Mailing Address - Fax:949-288-0429
Practice Address - Street 1:700 W 19TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3517
Practice Address - Country:US
Practice Address - Phone:949-645-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95007971363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily