Healthcare Provider Details

I. General information

NPI: 1437695632
Provider Name (Legal Business Name): CARRIE LEIGH HANEY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24854 S 470 RD
TAHLEQUAH OK
74464-1518
US

IV. Provider business mailing address

24854 S 470 RD
TAHLEQUAH OK
74464-1518
US

V. Phone/Fax

Practice location:
  • Phone: 918-457-9618
  • Fax:
Mailing address:
  • Phone: 918-457-9618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0069585
License Number StateOK

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: