Healthcare Provider Details

I. General information

NPI: 1992381982
Provider Name (Legal Business Name): BAROME ENOWEYERE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E 1ST ST
GRANITE OK
73547-9317
US

IV. Provider business mailing address

1700 E 1ST ST
GRANITE OK
73547-9317
US

V. Phone/Fax

Practice location:
  • Phone: 580-480-3700
  • Fax:
Mailing address:
  • Phone: 580-480-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201364
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: