MEDICARE: HEALTHYSPAN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1629864517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHYSPAN LLC

Provider Business Mailing Address
First Line	:	10324 GREENBRIAR PL STE C
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7650
Country	:	US
Telephone Number	:	405-822-0480
Fax Number	:	947-222-9272

Provider Business Practice Location Address
First Line	:	10324 GREENBRIAR PL STE C
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7650
Country	:	US
Telephone Number	:	405-822-0480
Fax Number	:	947-222-9272

Authorized Official
Title or Position	:	PMHNP, APRN-CNP
Name	:	IMELDA GARNER
Credential	:	PMHNP, APRN-CNP
Telephone Number	:	405-822-0480

Provider Enumeration Date	:	04/16/2025
Last Update Date	:	04/21/2025

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