Healthcare Provider Details

I. General information

NPI: 1205462801
Provider Name (Legal Business Name): ANDREA CORIN MANLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 S HOUSTON AVE
TULSA OK
74127-9043
US

IV. Provider business mailing address

1055 S HOUSTON AVE
TULSA OK
74127-9043
US

V. Phone/Fax

Practice location:
  • Phone: 918-921-3200
  • Fax:
Mailing address:
  • Phone: 918-921-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0121849
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number121849
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: