Provider Demographics
NPI:1073967246
Name:FARRIS, MARYSUE ELIZABETH (APRN)
Entity Type:Individual
Prefix:
First Name:MARYSUE
Middle Name:ELIZABETH
Last Name:FARRIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARYSUE
Other - Middle Name:ELIZABETH
Other - Last Name:SLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35737 HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:WANETTE
Mailing Address - State:OK
Mailing Address - Zip Code:74878-6025
Mailing Address - Country:US
Mailing Address - Phone:405-808-6160
Mailing Address - Fax:
Practice Address - Street 1:2900 S TELEPHONE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2968
Practice Address - Country:US
Practice Address - Phone:405-237-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0050272163WA2000X
OKF0816002363LF0000X
OK50272363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR0050272OtherRN LICENSE
OKF0816002OtherAANP CERTIFICATION