Healthcare Provider Details

I. General information

NPI: 1538899869
Provider Name (Legal Business Name): JODI LYNN ELDERTON DNP, APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/10/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W 15TH ST
EDMOND OK
73013-3747
US

IV. Provider business mailing address

416 W 15TH ST
EDMOND OK
73013-3747
US

V. Phone/Fax

Practice location:
  • Phone: 405-772-4699
  • Fax: 405-562-4996
Mailing address:
  • Phone: 405-772-4699
  • Fax: 405-562-4996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number207931
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: