Healthcare Provider Details

I. General information

NPI: 1053644716
Provider Name (Legal Business Name): STEFFANEE RENEE EDWARDS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEFFANEE RENEE STOCKTON

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S MAIN ST
WETUMKA OK
74883-4015
US

IV. Provider business mailing address

PO BOX 236
WETUMKA OK
74883-0236
US

V. Phone/Fax

Practice location:
  • Phone: 405-452-5400
  • Fax: 405-452-3000
Mailing address:
  • Phone: 405-452-5400
  • Fax: 405-452-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number57663
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: