Healthcare Provider Details

I. General information

NPI: 1477379121
Provider Name (Legal Business Name): STACY THORNLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 N JASPER DR STE 2
FLAGSTAFF AZ
86001-1634
US

IV. Provider business mailing address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

V. Phone/Fax

Practice location:
  • Phone: 866-974-2673
  • Fax: 480-499-8459
Mailing address:
  • Phone: 928-777-9600
  • Fax: 855-449-5560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number317682
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number317682
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: