Provider Demographics
NPI:1942593017
Name:GANNAWAY, STEPHANIE LYNN (AUD,CCC-A)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:GANNAWAY
Suffix:
Gender:F
Credentials:AUD,CCC-A
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD,CCC-A
Mailing Address - Street 1:PO BOX 960472
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0472
Mailing Address - Country:US
Mailing Address - Phone:405-755-6651
Mailing Address - Fax:405-755-2795
Practice Address - Street 1:3824 S BOULEVARD STE 110
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5779
Practice Address - Country:US
Practice Address - Phone:405-562-1810
Practice Address - Fax:405-562-1816
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3745231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200338810AMedicaid
OKOKAAA3879Medicare PIN