Provider Demographics
NPI:1407553597
Name:PAULS VALLEY FAMILY HEALTHCARE APRN FNP-BC LLC
Entity Type:Organization
Organization Name:PAULS VALLEY FAMILY HEALTHCARE APRN FNP-BC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTTY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-FNP-BC
Authorized Official - Phone:405-207-9238
Mailing Address - Street 1:34550 AIRLINE RD
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-9337
Mailing Address - Country:US
Mailing Address - Phone:405-207-9238
Mailing Address - Fax:
Practice Address - Street 1:34550 AIRLINE RD
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-9337
Practice Address - Country:US
Practice Address - Phone:405-207-9238
Practice Address - Fax:405-207-9240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK211329OtherOKLAHOMA STATE BOARD OF NURSING