Basic Information
| Provider Information | |||||||||
| NPI: | 1750373627 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UDELL | ||||||||
| FirstName: | MYRNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | A.R.N.P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N PORTER AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053290121 | ||||||||
| FaxNumber: | 4052926099 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 N PORTER AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053290121 | ||||||||
| FaxNumber: | 4052926099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 07/15/2010 | ||||||||
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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 | 363L00000X | R0031350 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200114590A | 05 | OK | MEDICAID |