Provider Demographics
NPI:1275607293
Name:TOMBERLIN, STACY LYNN (ARNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:TOMBERLIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:KATTERHENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:8440 WALNUT HILL LN STE 800
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-3825
Mailing Address - Country:US
Mailing Address - Phone:214-345-5999
Mailing Address - Fax:214-345-5988
Practice Address - Street 1:8440 WALNUT HILL LN STE 800
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-3825
Practice Address - Country:US
Practice Address - Phone:214-345-5999
Practice Address - Fax:214-345-5988
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0075357363L00000X
TXAP130049363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200102380AMedicaid
OK200102380AMedicaid
OKOK400269Medicare PIN