Provider Demographics
NPI:1043747595
Name:MOSS, STEPHANIE STANLEY (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:STANLEY
Last Name:MOSS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MICHELLE
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3737 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-1839
Mailing Address - Country:US
Mailing Address - Phone:479-246-1700
Mailing Address - Fax:479-631-2629
Practice Address - Street 1:3737 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-1839
Practice Address - Country:US
Practice Address - Phone:479-246-1700
Practice Address - Fax:479-631-2629
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2955152W00000X
390200000X
AR2763152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program