Healthcare Provider Details

I. General information

NPI: 1083197073
Provider Name (Legal Business Name): STACY MABRY RN PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 ACTIS RD
BAKERSFIELD CA
93309-5911
US

IV. Provider business mailing address

3100 ACTIS RD
BAKERSFIELD CA
93309-5911
US

V. Phone/Fax

Practice location:
  • Phone: 661-831-8331
  • Fax: 661-831-8256
Mailing address:
  • Phone: 661-831-8331
  • Fax: 661-831-8256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number525796
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: