Basic Information
Provider Information | |||||||||
NPI: | 1639692874 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRIES | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN-CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WEATHERS | ||||||||
OtherFirstName: | EMILY | ||||||||
OtherMiddleName: | H | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4120 W MEMORIAL RD STE 300 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731209306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057483300 | ||||||||
FaxNumber: | 4057491671 | ||||||||
Practice Location | |||||||||
Address1: | 4120 W MEMORIAL RD STE 300 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731209306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057483300 | ||||||||
FaxNumber: | 4057491671 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2017 | ||||||||
LastUpdateDate: | 05/21/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | 95624 | OK | N |   | Nursing Service Providers | Registered Nurse | Medical-Surgical | 363LF0000X | 95624 | OK | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WR0006X | 95624 | OK | Y |   | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.