Basic Information
| Provider Information | |||||||||
| NPI: | 1194935924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 W MEMORIAL RD | ||||||||
| Address2: | SUITE 708 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057490210 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 W MEMORIAL RD | ||||||||
| Address2: | SUITE 708 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057490210 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R0034330 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.