Basic Information
| Provider Information | |||||||||
| NPI: | 1548804206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYDERS | ||||||||
| FirstName: | STACEE | ||||||||
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| Credential: | CPNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5055 E BROADWAY BLVD STE A100 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857113629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203821085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2222 N CRAYCROFT RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202023488 | ||||||||
| FaxNumber: | 5202023486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2019 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 228942 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.