Healthcare Provider Details

I. General information

NPI: 1205831708
Provider Name (Legal Business Name): JENNIFER CAROL REXROAD C.R.N.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6839 S CANTON AVE
TULSA OK
74136-3402
US

IV. Provider business mailing address

903 N OSAGE ST
CHOUTEAU OK
74337-3777
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-0612
  • Fax: 918-481-5170
Mailing address:
  • Phone: 918-476-7779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0062121
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: