Healthcare Provider Details

I. General information

NPI: 1114270428
Provider Name (Legal Business Name): JENNIFER R ONTIVEROS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER REBECCA ROSE RICO

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4913 W RENO AVE
OKLAHOMA CITY OK
73127-6339
US

IV. Provider business mailing address

4913 W RENO AVE
OKLAHOMA CITY OK
73127-6339
US

V. Phone/Fax

Practice location:
  • Phone: 405-948-4900
  • Fax: 405-948-4919
Mailing address:
  • Phone: 405-948-4900
  • Fax: 405-948-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number99456
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number99456
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: