Provider Demographics
NPI:1477788891
Name:HASTEY, STACY MARIE (RD/LD)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:HASTEY
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20284 CEDAR RD.
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-7284
Mailing Address - Country:US
Mailing Address - Phone:918-756-5560
Mailing Address - Fax:888-322-5168
Practice Address - Street 1:714 W. 16TH ST.
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6218
Practice Address - Country:US
Practice Address - Phone:918-756-5560
Practice Address - Fax:888-322-5168
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1617133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200248390AMedicaid
OKOKB5648OtherMEDICARE PTAN