Healthcare Provider Details

I. General information

NPI: 1619788635
Provider Name (Legal Business Name): BLAINE K WHITSON APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5224 E I 240 SERVICE RD STE 100
OKLAHOMA CITY OK
73135-2607
US

IV. Provider business mailing address

7800 NW 85TH TER
OKLAHOMA CITY OK
73132-3385
US

V. Phone/Fax

Practice location:
  • Phone: 405-608-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberR0133962
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number221785
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: