Healthcare Provider Details

I. General information

NPI: 1982205449
Provider Name (Legal Business Name): VANESSA LYNN ZICKEFOOSE APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 S HARVARD AVE STE 209
TULSA OK
74135-2618
US

IV. Provider business mailing address

4415 S HARVARD AVE STE 209
TULSA OK
74135-2618
US

V. Phone/Fax

Practice location:
  • Phone: 539-202-1585
  • Fax: 539-202-1588
Mailing address:
  • Phone: 539-202-1585
  • Fax: 539-202-1588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0123057
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: