1922578707 NPI number — TAMARA JANE CAROL DAWN DEGENHARDT APRN

Table of content: TAMARA JANE CAROL DAWN DEGENHARDT APRN (NPI 1922578707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922578707 NPI number — TAMARA JANE CAROL DAWN DEGENHARDT APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEGENHARDT
Provider First Name:
TAMARA
Provider Middle Name:
JANE CAROL DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHMID
Provider Other First Name:
TAMARA
Provider Other Middle Name:
JANE CAROL DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922578707
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
809 FIREFORK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YUKON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73099-0504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-985-9940
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4205 OK-66
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL RENO
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73036-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-262-4875
Provider Business Practice Location Address Fax Number:
405-319-7675
Provider Enumeration Date:
12/05/2018

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: 363LF0000X , with the licence number:  91127 , 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: 91127 . This is a "BOARD OF NURSING LICENSE NUMBER" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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