=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649627332
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA YOUNG NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2016
-----------------------------------------------------
Last Update Date | 02/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1007 N COUNTRY CLUB RD
-----------------------------------------------------
City | ADA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74820-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-421-8700
-----------------------------------------------------
Fax | 580-421-8707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1007 N COUNTRY CLUB RD
-----------------------------------------------------
City | ADA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74820-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-421-8700
-----------------------------------------------------
Fax | 580-421-8707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 73114
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WS0200X
-----------------------------------------------------
Taxonomy Name | School Registered Nurse
-----------------------------------------------------
License Number | R 0073114
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------