Provider Demographics
NPI:1861186835
Name:DAVIS, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:DAVIS
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 1:230 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-6508
Mailing Address - Country:US
Mailing Address - Phone:580-332-3001
Mailing Address - Fax:580-332-8774
Practice Address - Street 1:230 E 12TH ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-6508
Practice Address - Country:US
Practice Address - Phone:580-332-3001
Practice Address - Fax:580-332-8774
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist