Healthcare Provider Details

I. General information

NPI: 1659007110
Provider Name (Legal Business Name): NICHOL M MCCONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E APACHE ST
TULSA OK
74106-3702
US

IV. Provider business mailing address

2455 N BOSTON AVE
TULSA OK
74106-3606
US

V. Phone/Fax

Practice location:
  • Phone: 918-794-0197
  • Fax:
Mailing address:
  • Phone: 918-812-4872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: