Provider Demographics
NPI:1952838104
Name:BUSH, STEPHANI NICHELLE
Entity Type:Individual
Prefix:
First Name:STEPHANI
Middle Name:NICHELLE
Last Name:BUSH
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 1:1325 N VINITA AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-6431
Mailing Address - Country:US
Mailing Address - Phone:918-772-0667
Mailing Address - Fax:
Practice Address - Street 1:1200 W 4TH ST STE D
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5013
Practice Address - Country:US
Practice Address - Phone:918-458-0113
Practice Address - Fax:918-458-0075
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator