Healthcare Provider Details

I. General information

NPI: 1356791891
Provider Name (Legal Business Name): SANDI LYNN CASEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST STE 101
TAHLEQUAH OK
74464-3354
US

IV. Provider business mailing address

2028 MAHANEY AVE
TAHLEQUAH OK
74464-5783
US

V. Phone/Fax

Practice location:
  • Phone: 918-708-3570
  • Fax: 918-453-2772
Mailing address:
  • Phone: 918-456-0001
  • Fax: 918-456-6383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77987
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200666850A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: