Basic Information
| Provider Information | |||||||||
| NPI: | 1548882103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUTHERFORD | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | DNAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5527 NIEMAN RD | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662032345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186334820 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 S BLISS AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744642512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2020 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 138975 | KS | N | Nursing Service Providers | Registered Nurse | 163W00000X | 117919 | OK | N | Nursing Service Providers | Registered Nurse | 367500000X | 117919 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.