Healthcare Provider Details

I. General information

NPI: 1275778060
Provider Name (Legal Business Name): IRIS RENEE BOREM C.N.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2008
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 S UTICA AVE SUITE 300
TULSA OK
74104-4243
US

IV. Provider business mailing address

1265 S UTICA AVE SUITE 300
TULSA OK
74104-4243
US

V. Phone/Fax

Practice location:
  • Phone: 918-592-0999
  • Fax: 918-592-1021
Mailing address:
  • Phone: 918-592-0999
  • Fax: 918-592-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberR0081229
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: