Healthcare Provider Details

I. General information

NPI: 1760910772
Provider Name (Legal Business Name): CHARLYSA DIANA GATLIN CASTILLO APRN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARLYSA DIANA GATLIN BRADY

II. Dates (important events)

Enumeration Date: 06/03/2017
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 COLONY DR
ADA OK
74820-2329
US

IV. Provider business mailing address

2900 S TELEPHONE RD STE 250
MOORE OK
73160-2969
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-5111
  • Fax:
Mailing address:
  • Phone: 405-237-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number105641
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: