Provider Demographics
NPI:1962724799
Name:STAIRES, MARILYN ANN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:ANN
Last Name:STAIRES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 E MARK LN
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-3392
Mailing Address - Country:US
Mailing Address - Phone:480-467-8665
Mailing Address - Fax:
Practice Address - Street 1:18614 W ONYX AVE
Practice Address - Street 2:
Practice Address - City:WADDELL
Practice Address - State:AZ
Practice Address - Zip Code:85355-4448
Practice Address - Country:US
Practice Address - Phone:480-467-8665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-21
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN106359163WP0808X
AZAP3646363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health