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General NPI Number Information
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NPI Number | 1720020076
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Entity Type | Individual
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Provider Name | DR. STACEY RAYBUCK
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Gender | Female
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Dates
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Enumeration Date | 06/12/2006
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Last Update Date | 05/19/2023
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Provider Practice Location Address
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Address Line | 101 WESTPARK DR
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City | BRENTWOOD
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State | TN
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Zip | 37027-5031
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Country | US
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Telephone | 910-310-4551
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Fax |
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Provider Business Mailing Address
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Address Line | 3250 N PIEDRA CIR
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City | MESA
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State | AZ
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Zip | 85207-0809
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 008112
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License Number State | AZ
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