Basic Information
| Provider Information | |||||||||
| NPI: | 1104826569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNAPP | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALE | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5300 N INDEPENDENCE AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059454587 | ||||||||
| FaxNumber: | 4057132735 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 NW 56TH ST # SREET100 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059512855 | ||||||||
| FaxNumber: | 4059512858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 07/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3962 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200035270A | 05 | OK | MEDICAID |