Provider Demographics
NPI:1629599204
Name:STEWART, MICHELLE RAE (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:STEWART
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RAE
Other - Last Name:OLDAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:505 W COMANCHE ST # A
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5616
Mailing Address - Country:US
Mailing Address - Phone:580-736-1372
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST BLDG 52
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5305
Practice Address - Country:US
Practice Address - Phone:405-307-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-04
Last Update Date:2017-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64158164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK64158OtherOKLAHOMA BOARD OF NURSING