Healthcare Provider Details

I. General information

NPI: 1285008227
Provider Name (Legal Business Name): STACEY ALETHEA WAGGONER APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY ALETHEA WAGGONER APRN-CNP

II. Dates (important events)

Enumeration Date: 11/13/2015
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6613 N MERIDIAN AVE
OKLAHOMA CITY OK
73116-1423
US

IV. Provider business mailing address

6613 N MERIDIAN AVE
OKLAHOMA CITY OK
73116-1423
US

V. Phone/Fax

Practice location:
  • Phone: 405-603-8450
  • Fax:
Mailing address:
  • Phone: 405-603-8450
  • Fax: 405-603-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number83425
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0083425
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: