Healthcare Provider Details

I. General information

NPI: 1578247243
Provider Name (Legal Business Name): CHECOTAH BRIT PARDUE RN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 STONECIPHER DR
ADA OK
74820-3439
US

IV. Provider business mailing address

1921 STONECIPHER DR
ADA OK
74820-3439
US

V. Phone/Fax

Practice location:
  • Phone: 580-421-4550
  • Fax:
Mailing address:
  • Phone: 580-421-4550
  • Fax: 580-421-8268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number211367
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: