MEDICARE: DOROTHY DIANE COCKBURN C.P.N.P.

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	363LP0200X	Pediatric Nurse Practitioner	R0024127	OK

General Provider Information

NPI Number	:	1730186651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOROTHY DIANE COCKBURN C.P.N.P.

Provider Business Mailing Address
First Line	:	1101 S BELMONT AVE
Second Line	:	STE 205
City	:	OKMULGEE
State	:	OK
Zip	:	74447-6315
Country	:	US
Telephone Number	:	918-756-8371
Fax Number	:	918-758-3437

Provider Business Practice Location Address
First Line	:	1101 S BELMONT AVE
Second Line	:	STE 205
City	:	OKMULGEE
State	:	OK
Zip	:	74447-6315
Country	:	US
Telephone Number	:	918-756-8371
Fax Number	:	918-758-3437

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/08/2007

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