1558358655 NPI number — MRS. BRENDA ELDER A.R.N.P.

Table of content: MRS. BRENDA ELDER A.R.N.P. (NPI 1558358655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558358655 NPI number — MRS. BRENDA ELDER A.R.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELDER
Provider First Name:
BRENDA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
A.R.N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELDER
Provider Other First Name:
BRENDA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
A.R.N.P.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1558358655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23778 S MITCHELL LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT GIBSON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-478-4394
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 SO. 41ST ST. EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUSKOGEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74403-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-687-0201
Provider Business Practice Location Address Fax Number:
918-687-0665
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  R0051899 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1751899 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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