Healthcare Provider Details

I. General information

NPI: 1962724799
Provider Name (Legal Business Name): MARILYN ANN STAIRES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2010
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18614 W ONYX AVE
WADDELL AZ
85355-4448
US

IV. Provider business mailing address

5105 E MARK LN
CAVE CREEK AZ
85331-3392
US

V. Phone/Fax

Practice location:
  • Phone: 480-467-8665
  • Fax:
Mailing address:
  • Phone: 480-467-8665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP3646
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN106359
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: