Provider Demographics
NPI:1164760245
Name:CANTWELL, STACY MARIE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:CANTWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:SHELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP
Mailing Address - Street 1:3030 N CENTRAL AVE STE 1001
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2716
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:485 S DOBSON RD STE 201
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:480-728-4728
Practice Address - Fax:480-728-4747
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22570363LA2100X
AZAP8669363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHB584ZMedicare UPIN