Healthcare Provider Details

I. General information

NPI: 1104373398
Provider Name (Legal Business Name): SHANNON ESPY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 S UTICA AVE
TULSA OK
74104-6520
US

IV. Provider business mailing address

1923 S UTICA AVE
TULSA OK
74104-6520
US

V. Phone/Fax

Practice location:
  • Phone: 918-403-7054
  • Fax:
Mailing address:
  • Phone: 918-403-7054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number80904
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: