Healthcare Provider Details

I. General information

NPI: 1194340307
Provider Name (Legal Business Name): AMANDA MARTIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7127 S OLYMPIA AVE
TULSA OK
74132-1856
US

IV. Provider business mailing address

701 CEDAR LAKE BLVD STE 160
OKLAHOMA CITY OK
73114-7818
US

V. Phone/Fax

Practice location:
  • Phone: 918-876-0521
  • Fax: 918-876-0939
Mailing address:
  • Phone: 405-724-0574
  • Fax: 405-849-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0117658
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: