Healthcare Provider Details

I. General information

NPI: 1790473585
Provider Name (Legal Business Name): ELISA RENEE JOSEPH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N MARTIN LUTHER KING AVE
OKLAHOMA CITY OK
73111-1401
US

IV. Provider business mailing address

3122 NW EXPRESSWAY APT 194
OKLAHOMA CITY OK
73112-4021
US

V. Phone/Fax

Practice location:
  • Phone: 405-694-0763
  • Fax:
Mailing address:
  • Phone: 405-694-0763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number207617
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number207617
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number207617
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number207617
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number207617
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code163WN1003X
TaxonomyNutrition Support Registered Nurse
License Number207617
License Number StateOK
# 7
Primary TaxonomyY
Taxonomy Code163WP1700X
TaxonomyPerinatal Registered Nurse
License Number207617
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: