Provider Demographics
NPI:1841740735
Name:STATHEALTH CLINIC
Entity Type:Organization
Organization Name:STATHEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:SEYMOUR
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:580-286-1095
Mailing Address - Street 1:1254 S LYNN LN
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-6813
Mailing Address - Country:US
Mailing Address - Phone:580-286-1095
Mailing Address - Fax:
Practice Address - Street 1:1254 S LYNN LN
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-6813
Practice Address - Country:US
Practice Address - Phone:580-286-1095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK85946261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care