Healthcare Provider Details

I. General information

NPI: 1649627332
Provider Name (Legal Business Name): LISA YOUNG NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 N COUNTRY CLUB RD
ADA OK
74820-2847
US

IV. Provider business mailing address

1007 N COUNTRY CLUB RD
ADA OK
74820-2847
US

V. Phone/Fax

Practice location:
  • Phone: 580-421-8700
  • Fax: 580-421-8707
Mailing address:
  • Phone: 580-421-8700
  • Fax: 580-421-8707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number73114
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR 0073114
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: