Healthcare Provider Details

I. General information

NPI: 1619704475
Provider Name (Legal Business Name): TASHA KAY CLEWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 N CLARENCE NASH BLVD
WATONGA OK
73772-3636
US

IV. Provider business mailing address

407 N CLARENCE NASH BLVD
WATONGA OK
73772-3636
US

V. Phone/Fax

Practice location:
  • Phone: 580-623-2233
  • Fax: 580-623-2232
Mailing address:
  • Phone: 580-623-2233
  • Fax: 580-623-2232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0129874
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number223996
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: