Healthcare Provider Details

I. General information

NPI: 1285273920
Provider Name (Legal Business Name): PSYCHIATRIC WELLNESS APRN-CNP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2019
Last Update Date: 01/15/2022
Certification Date: 01/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1491 S SUNNYLANE RD
DEL CITY OK
73115-3037
US

IV. Provider business mailing address

1491 S SUNNYLANE RD
DEL CITY OK
73115-3037
US

V. Phone/Fax

Practice location:
  • Phone: 405-437-2240
  • Fax: 661-231-3153
Mailing address:
  • Phone: 405-437-2240
  • Fax: 661-231-3153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELISABETH MUSTACHIA
Title or Position: OWNER
Credential: APRN-CNP
Phone: 405-437-2240