Provider Demographics
NPI:1174261366
Name:SHANNON, STACI N (BS)
Entity Type:Individual
Prefix:MS
First Name:STACI
Middle Name:N
Last Name:SHANNON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-3952
Mailing Address - Country:US
Mailing Address - Phone:918-834-4194
Mailing Address - Fax:918-834-4189
Practice Address - Street 1:3712 E 11TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-3952
Practice Address - Country:US
Practice Address - Phone:918-834-4194
Practice Address - Fax:918-834-4189
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker