=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336085778
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADALYNN ROLLER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2026
-----------------------------------------------------
Last Update Date | 04/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1027 E CHERRY ST
-----------------------------------------------------
City | CUSHING
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74023-4101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-225-2915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17423 S 89TH EAST AVE
-----------------------------------------------------
City | BIXBY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74008-6408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-261-5817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 209050
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------