Healthcare Provider Details

I. General information

NPI: 1629864517
Provider Name (Legal Business Name): HEALTHYSPAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10324 GREENBRIAR PL STE C
OKLAHOMA CITY OK
73159-7650
US

IV. Provider business mailing address

10324 GREENBRIAR PL STE C
OKLAHOMA CITY OK
73159-7650
US

V. Phone/Fax

Practice location:
  • Phone: 405-822-0480
  • Fax: 947-222-9272
Mailing address:
  • Phone: 405-822-0480
  • Fax: 947-222-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IMELDA GARNER
Title or Position: PMHNP, APRN-CNP
Credential: PMHNP, APRN-CNP
Phone: 405-822-0480