Provider Demographics
NPI:1033222401
Name:NICK, JEARLYN KAY (ARNP)
Entity Type:Individual
Prefix:
First Name:JEARLYN
Middle Name:KAY
Last Name:NICK
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 1:1805 SLEEPY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-7112
Mailing Address - Country:US
Mailing Address - Phone:918-759-2200
Mailing Address - Fax:918-759-2206
Practice Address - Street 1:1151 S BELMONT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6307
Practice Address - Country:US
Practice Address - Phone:918-759-2200
Practice Address - Fax:918-759-2206
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKROO46187363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1033222401OtherMEDICARE NPI
OK245701101Medicare PIN
OK1033222401OtherMEDICARE NPI