Provider Demographics
NPI:1730998782
Name:STANLY, ELIVE M
Entity type:Individual
Prefix:
First Name:ELIVE
Middle Name:M
Last Name:STANLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9950 W INDIAN SCHOOL RD UNIT 8
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5912
Mailing Address - Country:US
Mailing Address - Phone:443-527-1423
Mailing Address - Fax:
Practice Address - Street 1:2703 FORT BAKER DR SE APT 1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7274
Practice Address - Country:US
Practice Address - Phone:240-244-4863
Practice Address - Fax:443-513-2664
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-04
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX966854163WP0807X
DCCN221201831363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC010192714Medicaid