1114964913 NPI number — MRS. STACY LYNN BOOTHE CNS

Table of content: MRS. STACY LYNN BOOTHE CNS (NPI 1114964913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114964913 NPI number — MRS. STACY LYNN BOOTHE CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOOTHE
Provider First Name:
STACY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114964913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73070-1330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-515-2222
Provider Business Mailing Address Fax Number:
405-307-6660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 HEALTHPLEX PKWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73072-9738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-515-2222
Provider Business Practice Location Address Fax Number:
405-515-2251
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364S00000X , with the licence number:  R0072509 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200091170A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200091170 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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