Provider Demographics
NPI:1114500626
Name:KASTNER, STACY BO
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:BO
Last Name:KASTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 NW 67TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3417
Mailing Address - Country:US
Mailing Address - Phone:405-314-7396
Mailing Address - Fax:
Practice Address - Street 1:5350 S WESTERN AVE STE 709
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-4537
Practice Address - Country:US
Practice Address - Phone:405-623-9773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty