Healthcare Provider Details

I. General information

NPI: 1508317041
Provider Name (Legal Business Name): STACY HYDEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S TELEPHONE RD
MOORE OK
73160-2502
US

IV. Provider business mailing address

700 S TELEPHONE RD
MOORE OK
73160-2502
US

V. Phone/Fax

Practice location:
  • Phone: 405-912-3055
  • Fax: 405-912-3059
Mailing address:
  • Phone: 405-912-3055
  • Fax: 405-912-3059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1937
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: