Basic Information
| Provider Information | |||||||||
| NPI: | 1619965662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2915 E 97TH PL | ||||||||
| Address2: | APT 1201 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741377309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182969477 | ||||||||
| FaxNumber: | 9187481303 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717A S UTICA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187481300 | ||||||||
| FaxNumber: | 9187481303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 02/12/2009 | ||||||||
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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 | 363LF0000X | R0059141 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200039750A | 05 | OK | MEDICAID |