Provider Demographics
NPI:1194935924
Name:ROSE, STACEY LYNN (CNS)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:ROSE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 W MEMORIAL RD
Mailing Address - Street 2:SUITE 708
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9350
Mailing Address - Country:US
Mailing Address - Phone:405-749-0210
Mailing Address - Fax:405-292-5505
Practice Address - Street 1:4200 W MEMORIAL RD
Practice Address - Street 2:SUITE 708
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9350
Practice Address - Country:US
Practice Address - Phone:405-749-0210
Practice Address - Fax:405-292-5505
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0034330363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP53633Medicare UPIN