Provider Demographics
NPI:1275724635
Name:PUCKETT, STACY MICHELE (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MICHELE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7787 S 425 RD
Mailing Address - Street 2:
Mailing Address - City:INOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74036-5364
Mailing Address - Country:US
Mailing Address - Phone:918-691-8157
Mailing Address - Fax:
Practice Address - Street 1:7787 S 425 RD
Practice Address - Street 2:
Practice Address - City:INOLA
Practice Address - State:OK
Practice Address - Zip Code:74036-5364
Practice Address - Country:US
Practice Address - Phone:918-691-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4327235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist