Healthcare Provider Details

I. General information

NPI: 1568983401
Provider Name (Legal Business Name): STEPHANIE NICOLE FOSSETT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E ROSS BYP
TAHLEQUAH OK
74464-4188
US

IV. Provider business mailing address

1201 E ROSS BYPASS
TAHLEQUAH OK
74464
US

V. Phone/Fax

Practice location:
  • Phone: 918-207-0991
  • Fax: 918-456-7570
Mailing address:
  • Phone: 918-207-0991
  • Fax: 918-456-7570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101517
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: