Healthcare Provider Details

I. General information

NPI: 1194935924
Provider Name (Legal Business Name): STACEY LYNN ROSE CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W MEMORIAL RD SUITE 708
OKLAHOMA CITY OK
73120-9350
US

IV. Provider business mailing address

4200 W MEMORIAL RD SUITE 708
OKLAHOMA CITY OK
73120-9350
US

V. Phone/Fax

Practice location:
  • Phone: 405-749-0210
  • Fax: 405-292-5505
Mailing address:
  • Phone: 405-749-0210
  • Fax: 405-292-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR0034330
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: