Healthcare Provider Details

I. General information

NPI: 1275359945
Provider Name (Legal Business Name): JERRY MOYNIHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4028 W 42ND ST
TULSA OK
74107-6326
US

IV. Provider business mailing address

4028 W 42ND ST
TULSA OK
74107-6326
US

V. Phone/Fax

Practice location:
  • Phone: 512-571-3286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberJ081120129
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: