Healthcare Provider Details

I. General information

NPI: 1750050456
Provider Name (Legal Business Name): TAWNA LYNN PICKLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N EASTERN AVE
MOORE OK
73160-5833
US

IV. Provider business mailing address

400 N EASTERN AVE
MOORE OK
73160-5833
US

V. Phone/Fax

Practice location:
  • Phone: 405-757-7818
  • Fax:
Mailing address:
  • Phone: 405-757-7818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number205330
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: