Healthcare Provider Details

I. General information

NPI: 1316578842
Provider Name (Legal Business Name): AMANDA M DEL BOSQUE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 N COUNTRY CLUB RD
ADA OK
74820-2847
US

IV. Provider business mailing address

530 N MONTE VISTA ST STE A
ADA OK
74820-4675
US

V. Phone/Fax

Practice location:
  • Phone: 580-310-9510
  • Fax: 580-272-1094
Mailing address:
  • Phone: 580-310-9510
  • Fax: 580-436-4447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0114118
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0114118
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: