Healthcare Provider Details

I. General information

NPI: 1356143978
Provider Name (Legal Business Name): MANDA LYNN BLISS APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10505 E 91ST ST STE 205
TULSA OK
74133-5829
US

IV. Provider business mailing address

10505 E 91ST ST STE 205
TULSA OK
74133-5829
US

V. Phone/Fax

Practice location:
  • Phone: 918-307-5490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberR0121986
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number222648
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: