Healthcare Provider Details

I. General information

NPI: 1275724635
Provider Name (Legal Business Name): STACY MICHELE PUCKETT M.S.,CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STACY MOSES

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7787 S 425 RD
INOLA OK
74036-5364
US

IV. Provider business mailing address

7787 S 425 RD
INOLA OK
74036-5364
US

V. Phone/Fax

Practice location:
  • Phone: 918-691-8157
  • Fax:
Mailing address:
  • Phone: 918-691-8157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4327
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: