Provider Demographics
NPI:1003388497
Name:BUSH, KATRINA ANN
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:ANN
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 140114
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-0015
Mailing Address - Country:US
Mailing Address - Phone:918-896-9092
Mailing Address - Fax:
Practice Address - Street 1:1721 E OMAHA ST APT B3
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-0363
Practice Address - Country:US
Practice Address - Phone:918-896-9092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-22
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK68404164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse