Healthcare Provider Details

I. General information

NPI: 1073967246
Provider Name (Legal Business Name): MARYSUE ELIZABETH FARRIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARYSUE ELIZABETH SLACK

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S TELEPHONE RD SUITE 250
MOORE OK
73160-2968
US

IV. Provider business mailing address

35737 HAMILTON RD
WANETTE OK
74878-6025
US

V. Phone/Fax

Practice location:
  • Phone: 405-237-7500
  • Fax:
Mailing address:
  • Phone: 405-808-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberR0050272
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0816002
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number50272
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: