Provider Demographics
NPI:1679383095
Name:VANG, STACEY DAWN (RD/LD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:DAWN
Last Name:VANG
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:DIRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14142 N 73RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-4653
Mailing Address - Country:US
Mailing Address - Phone:918-352-5181
Mailing Address - Fax:
Practice Address - Street 1:1020 LENAPE DR
Practice Address - Street 2:
Practice Address - City:NOWATA
Practice Address - State:OK
Practice Address - Zip Code:74048-4403
Practice Address - Country:US
Practice Address - Phone:918-273-7538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2430133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered