Provider Demographics
NPI:1225556681
Name:SMITH, STACEY LYNN
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:PATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-8109
Mailing Address - Country:US
Mailing Address - Phone:580-622-8206
Mailing Address - Fax:580-622-6455
Practice Address - Street 1:2011 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-4221
Practice Address - Country:US
Practice Address - Phone:580-622-2161
Practice Address - Fax:580-622-6455
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK97016363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily