Healthcare Provider Details

I. General information

NPI: 1144929084
Provider Name (Legal Business Name): CASSIDY LORRAINE DUCRAY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 E BASELINE RD STE 129
MESA AZ
85206-4679
US

IV. Provider business mailing address

PO BOX 748817
ATLANTA GA
30374-8817
US

V. Phone/Fax

Practice location:
  • Phone: 480-644-1001
  • Fax: 480-464-8722
Mailing address:
  • Phone: 813-286-0033
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number288504
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberTEMP288504
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: