Healthcare Provider Details

I. General information

NPI: 1093760167
Provider Name (Legal Business Name): STACEY BETH GREGORY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 W TALAVI BLVD SUITE 180
GLENDALE AZ
85306-1886
US

IV. Provider business mailing address

4747 N 7TH ST SUITE 100
PHOENIX AZ
85014-3653
US

V. Phone/Fax

Practice location:
  • Phone: 623-486-8202
  • Fax: 623-486-2739
Mailing address:
  • Phone: 602-279-7655
  • Fax: 602-264-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP009026
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP3709
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number400916
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number304376
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: