Provider Demographics
NPI:1033117072
Name:DETERDING, JEANINE DIANNE (ARNP)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:DIANNE
Last Name:DETERDING
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2001
Mailing Address - Country:US
Mailing Address - Phone:580-762-3342
Mailing Address - Fax:580-762-5841
Practice Address - Street 1:306 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2001
Practice Address - Country:US
Practice Address - Phone:580-762-3342
Practice Address - Fax:580-762-5841
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0045604163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice