Healthcare Provider Details

I. General information

NPI: 1285417295
Provider Name (Legal Business Name): STACI RYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 N 7TH ST APT 139
PHOENIX AZ
85014-5409
US

IV. Provider business mailing address

3030 N 7TH ST APT 139
PHOENIX AZ
85014-5409
US

V. Phone/Fax

Practice location:
  • Phone: 202-297-1207
  • Fax:
Mailing address:
  • Phone: 202-297-1207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT24185
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: