Healthcare Provider Details

I. General information

NPI: 1366904740
Provider Name (Legal Business Name): LISA ANN BLOXHAM APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12697 E 51ST ST
TULSA OK
74146-6236
US

IV. Provider business mailing address

3404 W KNOXVILLE ST
BROKEN ARROW OK
74012-4657
US

V. Phone/Fax

Practice location:
  • Phone: 918-505-3200
  • Fax:
Mailing address:
  • Phone: 918-645-9411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberR0099475
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number99475
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: