Healthcare Provider Details

I. General information

NPI: 1508408394
Provider Name (Legal Business Name): SHANDA LYNN GOWER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2019
Last Update Date: 10/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 W LINDSEY ST
NORMAN OK
73069-4101
US

IV. Provider business mailing address

1807 W LINDSEY ST
NORMAN OK
73069-4101
US

V. Phone/Fax

Practice location:
  • Phone: 405-579-4673
  • Fax:
Mailing address:
  • Phone: 405-579-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number81012
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: