Healthcare Provider Details

I. General information

NPI: 1134055213
Provider Name (Legal Business Name): GREEN LIFE HEALTH AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 W MAIN ST
PURCELL OK
73080-4222
US

IV. Provider business mailing address

218 W MAIN ST
PURCELL OK
73080-4222
US

V. Phone/Fax

Practice location:
  • Phone: 405-464-9370
  • Fax:
Mailing address:
  • Phone: 405-464-9370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RANDI CHANTEL MARTIN
Title or Position: OWNER
Credential: NP
Phone: 405-464-9370