Healthcare Provider Details

I. General information

NPI: 1023657434
Provider Name (Legal Business Name): STEFANY SUE MOORE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N PORTER AVE
NORMAN OK
73071-6404
US

IV. Provider business mailing address

PO BOX 52
VERDEN OK
73092-0052
US

V. Phone/Fax

Practice location:
  • Phone: 405-307-1500
  • Fax:
Mailing address:
  • Phone: 405-274-9671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number109496
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF01200268
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR0109496
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: