MEDICARE: STACY LACKEY M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	329	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265575609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY LACKEY M.S.

Provider Business Mailing Address
First Line	:	5635 N MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74126-6409
Country	:	US
Telephone Number	:	918-594-4731
Fax Number	:	918-595-4269

Provider Business Practice Location Address
First Line	:	5635 N MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74126-6409
Country	:	US
Telephone Number	:	918-594-4731
Fax Number	:	918-595-4269

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	04/02/2015

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Directions to “ STACY LACKEY M.S.” Practice Location

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