Healthcare Provider Details

I. General information

NPI: 1336616713
Provider Name (Legal Business Name): CARLY STRUS APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 N COMMERCE ST STE 246
ARDMORE OK
73401-1394
US

IV. Provider business mailing address

2007 N COMMERCE ST STE 246
ARDMORE OK
73401-1394
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-3003
  • Fax: 580-798-3124
Mailing address:
  • Phone: 580-226-3003
  • Fax: 580-798-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number112615
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number0112615
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: