Healthcare Provider Details

I. General information

NPI: 1538675095
Provider Name (Legal Business Name): LUCY ELLEN GARTH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 S MUSTANG RD
YUKON OK
73099-6754
US

IV. Provider business mailing address

428 S MUSTANG RD
YUKON OK
73099-6754
US

V. Phone/Fax

Practice location:
  • Phone: 405-544-5477
  • Fax:
Mailing address:
  • Phone: 405-544-5477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR0091845
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: