Healthcare Provider Details

I. General information

NPI: 1063555191
Provider Name (Legal Business Name): CARMELLA RENAE STALEY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. CARMELLA RENAE LANCASTER

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 W SOUTHERN AVE
APACHE JUNCTION AZ
85220-7456
US

IV. Provider business mailing address

5735 E MCDOWELL RD LOT 343
MESA AZ
85215-1448
US

V. Phone/Fax

Practice location:
  • Phone: 480-982-1110
  • Fax: 480-474-8370
Mailing address:
  • Phone: 480-830-7530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP033913
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: