Provider Demographics
NPI:1457825432
Name:EBERLE, AMY L
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:EBERLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N PORTLAND AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2131
Mailing Address - Country:US
Mailing Address - Phone:405-604-4202
Mailing Address - Fax:
Practice Address - Street 1:3433 NW 56TH ST STE 400
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4430
Practice Address - Country:US
Practice Address - Phone:405-947-3341
Practice Address - Fax:405-951-4358
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK87638364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK87638OtherOKLAHOMA LICENSE