Provider Demographics
NPI:1912376765
Name:PROVENCE, STACY DANIELLE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:DANIELLE
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 NW 39TH EXPY
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-2513
Mailing Address - Country:US
Mailing Address - Phone:405-789-6711
Mailing Address - Fax:405-440-6716
Practice Address - Street 1:6800 NW 39TH EXPY
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2513
Practice Address - Country:US
Practice Address - Phone:405-789-6711
Practice Address - Fax:405-440-6716
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0089753363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics