Provider Demographics
NPI:1194008151
Name:MOURNING, NICOLE JANEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JANEL
Last Name:MOURNING
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:JANEL
Other - Last Name:HAZELWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15100 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1108
Mailing Address - Country:US
Mailing Address - Phone:405-330-3742
Mailing Address - Fax:
Practice Address - Street 1:15100 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1108
Practice Address - Country:US
Practice Address - Phone:405-330-3742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13978183500000X
TX43449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist