Healthcare Provider Details

I. General information

NPI: 1548448087
Provider Name (Legal Business Name): STACY LUANN ELLIS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 N VAN BUREN ST
ENID OK
73703-1729
US

IV. Provider business mailing address

3001 QUAIL SPRINGS PKWY FL 5
OKLAHOMA CITY OK
73134-2640
US

V. Phone/Fax

Practice location:
  • Phone: 580-616-6340
  • Fax: 580-616-3644
Mailing address:
  • Phone: 580-616-6340
  • Fax: 580-616-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1724
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: