Healthcare Provider Details

I. General information

NPI: 1336085778
Provider Name (Legal Business Name): MADALYNN ROLLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 E CHERRY ST
CUSHING OK
74023-4101
US

IV. Provider business mailing address

17423 S 89TH EAST AVE
BIXBY OK
74008-6408
US

V. Phone/Fax

Practice location:
  • Phone: 918-225-2915
  • Fax:
Mailing address:
  • Phone: 918-261-5817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209050
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: