Healthcare Provider Details

I. General information

NPI: 1285177717
Provider Name (Legal Business Name): STORMY STOY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2016
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S HARRILL AVE
WAGONER OK
74467-5317
US

IV. Provider business mailing address

109 S HARRILL AVE
WAGONER OK
74467-5317
US

V. Phone/Fax

Practice location:
  • Phone: 918-485-0242
  • Fax: 918-485-0204
Mailing address:
  • Phone: 918-485-0242
  • Fax: 918-485-0204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: