Provider Demographics
NPI:1477584118
Name:GOURDOUX, STACEY ANN (ANP-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:GOURDOUX
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 E BROADWAY RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1346
Mailing Address - Country:US
Mailing Address - Phone:480-290-7000
Mailing Address - Fax:602-254-6840
Practice Address - Street 1:2550 W UNION HILLS DR STE 390
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-5197
Practice Address - Country:US
Practice Address - Phone:602-443-4068
Practice Address - Fax:623-434-8310
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN060766163WG0000X
AZAP2224363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ332832Medicaid
AZAP2224OtherLICENSE