Provider Demographics
NPI:1285008227
Name:WAGGONER, STACEY ALETHEA (APRN-CNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ALETHEA
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ALETHEA
Other - Last Name:WAGGONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-CNP
Mailing Address - Street 1:6613 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1423
Mailing Address - Country:US
Mailing Address - Phone:405-603-8450
Mailing Address - Fax:405-603-8454
Practice Address - Street 1:6613 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1423
Practice Address - Country:US
Practice Address - Phone:405-603-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK83425363LF0000X
OK0083425363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200626780AMedicaid