Provider Demographics
NPI:1295404994
Name:ANTWINE, DEANDRA LYNETTE (APRN-CNP)
Entity Type:Individual
Prefix:MRS
First Name:DEANDRA
Middle Name:LYNETTE
Last Name:ANTWINE
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 S QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3803
Mailing Address - Country:US
Mailing Address - Phone:918-510-8266
Mailing Address - Fax:
Practice Address - Street 1:591 E 36TH ST N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-1812
Practice Address - Country:US
Practice Address - Phone:918-619-4400
Practice Address - Fax:918-634-7875
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK200784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty