Provider Demographics
NPI:1134640162
Name:STACY, LAUREL ELIZABETH (DO)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:ELIZABETH
Last Name:STACY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 S UTICA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4013
Mailing Address - Country:US
Mailing Address - Phone:918-579-3825
Mailing Address - Fax:
Practice Address - Street 1:1030 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4102
Practice Address - Country:US
Practice Address - Phone:918-225-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6503207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty