Provider Demographics
NPI:1083949788
Name:FOGARTY, STEFANIE LEE (ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:LEE
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:LEE
Other - Last Name:CASEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP-BC
Mailing Address - Street 1:1364 S PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296
Mailing Address - Country:US
Mailing Address - Phone:480-256-4500
Mailing Address - Fax:480-256-4123
Practice Address - Street 1:2946 E BANNER GATEWAY DR.
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-4683
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3757363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ558143Medicaid
AZZ140974Medicare PIN