Healthcare Provider Details

I. General information

NPI: 1003645409
Provider Name (Legal Business Name): MELISSA ISLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE
TULSA OK
74104-4012
US

IV. Provider business mailing address

1714 E MONTGOMERY PL
BROKEN ARROW OK
74012-1842
US

V. Phone/Fax

Practice location:
  • Phone: 918-592-0999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number219615
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: