Healthcare Provider Details

I. General information

NPI: 1174131288
Provider Name (Legal Business Name): SUSANNA CAROL MCDANIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 S UTICA AVE STE 701
TULSA OK
74104-4019
US

IV. Provider business mailing address

2401 W OMAHA ST APT 2315
BROKEN ARROW OK
74012-0652
US

V. Phone/Fax

Practice location:
  • Phone: 918-582-6544
  • Fax: 918-550-7544
Mailing address:
  • Phone: 918-856-1385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number82443
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number82443
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: