Provider Demographics
NPI:1225542905
Name:VANNARATH, CHAN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:CHAN
Middle Name:
Last Name:VANNARATH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 PITMAN ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73503-4473
Mailing Address - Country:US
Mailing Address - Phone:580-585-5600
Mailing Address - Fax:
Practice Address - Street 1:4303 PITMAN ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73503-4473
Practice Address - Country:US
Practice Address - Phone:580-585-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK84017363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1879OtherNURSE PRACTITIONER