MEDICARE: AMY C. COSTNER-LARK 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	100294	OK

General Provider Information

NPI Number	:	1770537037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY C. COSTNER-LARK APRN-CNP

Provider Business Mailing Address
First Line	:	5300 N INDEPENDENCE AVE
Second Line	:	SUITE 280
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-5556
Country	:	US
Telephone Number	:	405-713-9930
Fax Number	:	405-713-9931

Provider Business Practice Location Address
First Line	:	3366 NW EXPRESSWAY STE 200
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4416
Country	:	US
Telephone Number	:	405-713-9930
Fax Number	:	405-713-9931

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	08/22/2019

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