MEDICARE: TAMARA JANE CAROL DAWN DEGENHARDT APRN

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	363LF0000X	Family Nurse Practitioner	91127	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	91127	OTHER	OK	BOARD OF NURSING LICENSE NUMBER

General Provider Information

NPI Number	:	1922578707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA JANE CAROL DAWN DEGENHARDT APRN

Provider Business Mailing Address
First Line	:	809 FIREFORK AVE
Second Line	:
City	:	YUKON
State	:	OK
Zip	:	73099-0504
Country	:	US
Telephone Number	:	405-985-9940
Fax Number	:

Provider Business Practice Location Address
First Line	:	4205 OK-66
Second Line	:
City	:	EL RENO
State	:	OK
Zip	:	73036-4909
Country	:	US
Telephone Number	:	405-262-4875
Fax Number	:	405-319-7675

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

Provider Enumeration Date	:	12/05/2018
Last Update Date	:	06/01/2023

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