Provider Demographics
NPI:1275263931
Name:STORY, STASIA NICOLE
Entity Type:Individual
Prefix:
First Name:STASIA
Middle Name:NICOLE
Last Name:STORY
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 1:358 COUNTY ROAD 32050
Mailing Address - Street 2:
Mailing Address - City:BROOKSTON
Mailing Address - State:TX
Mailing Address - Zip Code:75421-2508
Mailing Address - Country:US
Mailing Address - Phone:903-401-7785
Mailing Address - Fax:
Practice Address - Street 1:212 EAST DUKE ST.
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743
Practice Address - Country:US
Practice Address - Phone:580-326-2200
Practice Address - Fax:580-326-2201
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator