Provider Demographics
NPI:1598407579
Name:SANDERS, STACEY GAYLE (NP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:GAYLE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4527 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-9076
Mailing Address - Country:US
Mailing Address - Phone:580-504-1988
Mailing Address - Fax:
Practice Address - Street 1:317 N ROCKFORD RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2552
Practice Address - Country:US
Practice Address - Phone:580-319-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK206990363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily