MEDICARE: STACY KIT RICKERD DNP, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	255641	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	23355143	OTHER	AZ	NCSBN
2	255641	OTHER	AZ	AZ STATE BOARD OF NURSING

General Provider Information

NPI Number	:	1275140972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY KIT RICKERD DNP, PMHNP-BC

Provider Business Mailing Address
First Line	:	1515 E OSBORN RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-5309
Country	:	US
Telephone Number	:	602-604-0000
Fax Number	:	602-604-5863

Provider Business Practice Location Address
First Line	:	1667 N TREKELL RD STE 103
Second Line	:
City	:	CASA GRANDE
State	:	AZ
Zip	:	85122-2731
Country	:	US
Telephone Number	:	520-876-5833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2020
Last Update Date	:	02/21/2025

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