Healthcare Provider Details

I. General information

NPI: 1245429596
Provider Name (Legal Business Name): MS. TAMARA KAREN MCDONOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 VALLEY RIM CT
SHAWNEE OK
74804-8925
US

IV. Provider business mailing address

112 VALLEY RIM CT
SHAWNEE OK
74804-8925
US

V. Phone/Fax

Practice location:
  • Phone: 405-273-7678
  • Fax:
Mailing address:
  • Phone: 405-273-7678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number493889
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0065709
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number2007002506-32
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: