Provider Demographics
NPI:1548560402
Name:GILLESPIE, STASHA LARAE
Entity Type:Individual
Prefix:MRS
First Name:STASHA
Middle Name:LARAE
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STASHA
Other - Middle Name:LARAE
Other - Last Name:BLAKELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4636 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2908
Mailing Address - Country:US
Mailing Address - Phone:918-382-7300
Mailing Address - Fax:
Practice Address - Street 1:4636 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-382-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator