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General NPI Number Information
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NPI Number | 1205956430
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Entity Type | Individual
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Provider Name | STACY RENEE MOORE A.T.C.
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Gender | Female
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 08/15/2014
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Provider Practice Location Address
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Address Line | 20370 ELM ST
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City | HARRAH
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State | OK
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Zip | 73045-9110
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Country | US
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Telephone | 405-347-2109
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Fax | 405-454-6842
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Provider Business Mailing Address
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Address Line | 5670 HENNEY PL
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City | CHOCTAW
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State | OK
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Zip | 73020-9134
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Country | US
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Telephone | 405-990-1199
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 427
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License Number State | OK
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