Basic Information
| Provider Information | |||||||||
| NPI: | 1104054147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORCH-PETITT | ||||||||
| FirstName: | LISHA | ||||||||
| MiddleName: | RYANNE | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N HARVARD AVE | ||||||||
| Address2: | STE E | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741154957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188326049 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2000 S WHEELING AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187487854 | ||||||||
| FaxNumber: | 9182933116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 07/31/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 0058269 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
No ID Information.