Healthcare Provider Details

I. General information

NPI: 1326314428
Provider Name (Legal Business Name): SHANAN ZICKEFOOSE RN, COSMETIC TATTOO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANAN ZICKEFOOSE BSN, RN, CPCP

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 10/22/2022
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3319 E 46TH ST SUITE 100
TULSA OK
74135-7413
US

IV. Provider business mailing address

4870 S LEWIS AVE SUITE 130
TULSA OK
74105-5151
US

V. Phone/Fax

Practice location:
  • Phone: 918-724-5614
  • Fax:
Mailing address:
  • Phone: 918-724-5614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZA2600X
TaxonomyMedical Art Specialist/Technologist
License Number1132
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code246ZA2600X
TaxonomyMedical Art Specialist/Technologist
License Number1132
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: