Healthcare Provider Details

I. General information

NPI: 1831583137
Provider Name (Legal Business Name): KYLIE MISHAEL SELF BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W MAIN ST
DURANT OK
74701-5038
US

IV. Provider business mailing address

82 BLUE STEM ROAD
CADDO OK
74729-3019
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-7330
  • Fax:
Mailing address:
  • Phone: 580-434-2719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 0110761
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: