Healthcare Provider Details

I. General information

NPI: 1013380385
Provider Name (Legal Business Name): MY FAMILY HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2015
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 N 19TH AVE BLDG 2
DURANT OK
74701-3017
US

IV. Provider business mailing address

1004 N 19TH AVE BLDG 2
DURANT OK
74701-3017
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-5622
  • Fax: 580-745-5060
Mailing address:
  • Phone: 580-924-5622
  • Fax: 580-745-5060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER RENEE NELSON
Title or Position: HEALTH CARE PROVIDER
Credential: APRN
Phone: 580-924-5622