Healthcare Provider Details

I. General information

NPI: 1558358655
Provider Name (Legal Business Name): BRENDA ELDER A.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA ELDER A.R.N.P.

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SO. 41ST ST. EAST
MUSKOGEE OK
74403-1404
US

IV. Provider business mailing address

23778 S MITCHELL LANE
FORT GIBSON OK
74434
US

V. Phone/Fax

Practice location:
  • Phone: 918-687-0201
  • Fax: 918-687-0665
Mailing address:
  • Phone: 918-478-4394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR0051899
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: