Healthcare Provider Details

I. General information

NPI: 1811321102
Provider Name (Legal Business Name): MAIN STREET FAMILY CLINIC APRN-CNP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W MAIN ST
JENKS OK
74037-2311
US

IV. Provider business mailing address

1201 W MAIN ST
JENKS OK
74037-2311
US

V. Phone/Fax

Practice location:
  • Phone: 918-518-5770
  • Fax: 918-518-5773
Mailing address:
  • Phone: 918-518-5770
  • Fax: 918-518-5773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberR00035175
License Number StateOK

VIII. Authorized Official

Name: MRS. DEBRA BEISTLE SCHROEDER
Title or Position: FAMILY NURSE PRACTITIONER
Credential: APRN-CNP
Phone: 918-518-5770