Provider Demographics
NPI:1568983401
Name:FOSSETT, STEPHANIE NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:FOSSETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 E ROSS BYPASS
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464
Mailing Address - Country:US
Mailing Address - Phone:918-207-0991
Mailing Address - Fax:918-456-7570
Practice Address - Street 1:1201 E ROSS BYP
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4188
Practice Address - Country:US
Practice Address - Phone:918-207-0991
Practice Address - Fax:918-456-7570
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101517363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily