MEDICARE: CHELSEA AGENT REAL DNP, APRN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	109534	OK
2	163W00000X	Registered Nurse	R096514	AR
3	363LF0000X	Family Nurse Practitioner	A005342	AR
4	363LF0000X	Family Nurse Practitioner	109534	OK

General Provider Information

NPI Number	:	1497280630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHELSEA AGENT REAL DNP, APRN, FNP-C

Provider Business Mailing Address
First Line	:	1015 E CHOCTAW AVE
Second Line	:
City	:	SALLISAW
State	:	OK
Zip	:	74955-5011
Country	:	US
Telephone Number	:	918-774-0034
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 E CHOCTAW AVE
Second Line	:
City	:	SALLISAW
State	:	OK
Zip	:	74955-5011
Country	:	US
Telephone Number	:	918-774-0034
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2017
Last Update Date	:	12/21/2018

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