Provider Demographics
NPI:1114930229
Name:MERIDETH, MARY CATHRYN (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHRYN
Last Name:MERIDETH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:CATHRYN
Other - Middle Name:SULLIVAN
Other - Last Name:MERIDETH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:530 N MONTE VISTA
Mailing Address - Street 2:SUITE A
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4675
Mailing Address - Country:US
Mailing Address - Phone:580-436-7101
Mailing Address - Fax:580-436-4447
Practice Address - Street 1:2017 W I 35 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8504
Practice Address - Country:US
Practice Address - Phone:405-509-2800
Practice Address - Fax:405-509-2885
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0077161363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200044620AMedicaid
OK248635701Medicare PIN
OK200044620AMedicaid