Basic Information
| Provider Information | |||||||||
| NPI: | 1447271564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUCKY-HEIL | ||||||||
| FirstName: | MARY JO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SENTA | ||||||||
| OtherFirstName: | MARY JO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6116 E ARBOR AVE STE 112 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852066103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806415400 | ||||||||
| FaxNumber: | 4802184353 | ||||||||
| Practice Location | |||||||||
| Address1: | 6116 E ARBOR AVE | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852066107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806415400 | ||||||||
| FaxNumber: | 4802184353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN096578 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | AP2518 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 136797 | 05 | AZ | MEDICAID |