Provider Demographics
NPI:1205956430
Name:MOORE, STACY RENEE (ATC)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5670 HENNEY PL
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-9134
Mailing Address - Country:US
Mailing Address - Phone:405-990-1199
Mailing Address - Fax:
Practice Address - Street 1:20370 ELM ST
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045-9110
Practice Address - Country:US
Practice Address - Phone:405-347-2109
Practice Address - Fax:405-454-6842
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer