Provider Demographics
NPI:1114964913
Name:BOOTHE, STACY LYNN (CNS)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-515-2222
Mailing Address - Fax:405-307-6660
Practice Address - Street 1:3500 HEALTHPLEX PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-9738
Practice Address - Country:US
Practice Address - Phone:405-515-2222
Practice Address - Fax:405-515-2251
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0072509364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200091170AMedicaid
OK200091170Medicaid
OK200091170Medicaid
OK200091170Medicaid
OK249622803Medicare PIN