Provider Demographics
NPI:1902305139
Name:ANDERSON, STEPHANIE LEE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15599 E 78TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-6036
Mailing Address - Country:US
Mailing Address - Phone:918-849-6362
Mailing Address - Fax:
Practice Address - Street 1:15599 E 78TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6036
Practice Address - Country:US
Practice Address - Phone:918-849-6362
Practice Address - Fax:918-849-6362
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator