Provider Demographics
NPI:1386492965
Name:ANDERSON, STEPHANIE MICHELLE (BSN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 N 17TH ST W
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-2437
Mailing Address - Country:US
Mailing Address - Phone:918-710-8501
Mailing Address - Fax:
Practice Address - Street 1:1401 MORRIS DR
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6429
Practice Address - Country:US
Practice Address - Phone:918-756-4233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0113867163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse