Healthcare Provider Details

I. General information

NPI: 1942864426
Provider Name (Legal Business Name): KRYSTAL K ROGERS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTAL K BANEY KRYSTAL HOUGHTELLING

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 E 51ST ST
TULSA OK
74134-6712
US

IV. Provider business mailing address

12902 E 51ST ST
TULSA OK
74134-6712
US

V. Phone/Fax

Practice location:
  • Phone: 918-994-3476
  • Fax: 918-995-3006
Mailing address:
  • Phone: 918-994-3476
  • Fax: 918-995-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60513914
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number56934
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0069713
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: