1144929084 NPI number — CASSIDY LORRAINE DUCRAY

Table of content: CASSIDY LORRAINE DUCRAY (NPI 1144929084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144929084 NPI number — CASSIDY LORRAINE DUCRAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUCRAY
Provider First Name:
CASSIDY
Provider Middle Name:
LORRAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144929084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6730
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85246-6730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-821-3600
Provider Business Mailing Address Fax Number:
480-857-2667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1142 E SOUTHERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85204-5055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-821-3628
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LX0001X , with the licence number:  TEMP288504 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 288504 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 016545 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: TEMP288504 . This is a "FNP LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".