Healthcare Provider Details

I. General information

NPI: 1417071036
Provider Name (Legal Business Name): DESHEA DONOVAN CARTER ARPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DESHEA DONOVAN MITCHELL ARPN

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

605 W 3RD ST
TAHLEQUAH OK
74464-4624
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3100
  • Fax:
Mailing address:
  • Phone: 918-822-7758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number100954
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: