Provider Demographics
NPI:1770236721
Name:STEWART, TRACI (FNP-BC)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472555 E 1070 RD
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-6683
Mailing Address - Country:US
Mailing Address - Phone:479-353-1528
Mailing Address - Fax:
Practice Address - Street 1:106 HOWARD ST
Practice Address - Street 2:
Practice Address - City:POCOLA
Practice Address - State:OK
Practice Address - Zip Code:74902-3523
Practice Address - Country:US
Practice Address - Phone:918-564-2217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK206033363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty