Provider Demographics
NPI:1255976643
Name:PENNIE, STEPHANIE (NP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PENNIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6135 S 90TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6365
Mailing Address - Country:US
Mailing Address - Phone:539-215-5609
Mailing Address - Fax:539-233-2480
Practice Address - Street 1:6135 S 90TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6365
Practice Address - Country:US
Practice Address - Phone:539-215-5609
Practice Address - Fax:539-233-2480
Is Sole Proprietor?:No
Enumeration Date:2019-11-09
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
OK206285363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program