Healthcare Provider Details

I. General information

NPI: 1114309317
Provider Name (Legal Business Name): DESTINY RUOSA MITCHELL APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 GRAND CASINO BLVD
SHAWNEE OK
74804-1005
US

IV. Provider business mailing address

781 GRAND CASINO BLVD
SHAWNEE OK
74804-1005
US

V. Phone/Fax

Practice location:
  • Phone: 405-964-5770
  • Fax: 405-964-5788
Mailing address:
  • Phone: 405-964-5770
  • Fax: 405-964-5788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number79374
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: