Provider Demographics
NPI:1326314428
Name:ZICKEFOOSE, SHANAN (RN, COSMETIC TATTOO)
Entity Type:Individual
Prefix:
First Name:SHANAN
Middle Name:
Last Name:ZICKEFOOSE
Suffix:
Gender:F
Credentials:RN, COSMETIC TATTOO
Other - Prefix:
Other - First Name:SHANAN
Other - Middle Name:
Other - Last Name:ZICKEFOOSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSN, RN, CPCP
Mailing Address - Street 1:4870 S LEWIS AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-5151
Mailing Address - Country:US
Mailing Address - Phone:918-724-5614
Mailing Address - Fax:
Practice Address - Street 1:3319 E 46TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7413
Practice Address - Country:US
Practice Address - Phone:918-724-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2022-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1132246ZA2600X
1132246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical