Provider Demographics
NPI:1295229623
Name:WERNEKE, AMANDA JEAN (APRN-CRNA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:WERNEKE
Suffix:
Gender:F
Credentials:APRN-CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E PECAN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-6192
Mailing Address - Country:US
Mailing Address - Phone:580-379-5860
Mailing Address - Fax:580-379-5859
Practice Address - Street 1:1200 E PECAN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6192
Practice Address - Country:US
Practice Address - Phone:580-379-5860
Practice Address - Fax:580-379-5859
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106409367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200773860AMedicaid