MEDICARE: LARYSA LESHELL WISE APRN-CNP

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	363LF0000X	Family Nurse Practitioner	F0716709	OK

General Provider Information

NPI Number	:	1710430897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARYSA LESHELL WISE APRN-CNP

Provider Business Mailing Address
First Line	:	2424 E 21ST ST STE 425
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74114-1727
Country	:	US
Telephone Number	:	918-779-7582
Fax Number	:

Provider Business Practice Location Address
First Line	:	2424 E 21ST ST STE 425
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74114-1727
Country	:	US
Telephone Number	:	918-779-7582
Fax Number	:	918-779-7587

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

Provider Enumeration Date	:	07/26/2016
Last Update Date	:	02/19/2025

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