Healthcare Provider Details

I. General information

NPI: 1619298346
Provider Name (Legal Business Name): NICOLE LYNN CUPP D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 SE DEBELL AVE
BARTLESVILLE OK
74006-2343
US

IV. Provider business mailing address

226 SE DEBELL AVE
BARTLESVILLE OK
74006-2343
US

V. Phone/Fax

Practice location:
  • Phone: 918-876-0476
  • Fax: 918-876-0479
Mailing address:
  • Phone: 918-876-0476
  • Fax: 918-876-0479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number301
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: