Provider Demographics
NPI:1487226981
Name:WENNERSTEN, CHAVON HOLLAND (APRN)
Entity Type:Individual
Prefix:
First Name:CHAVON
Middle Name:HOLLAND
Last Name:WENNERSTEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:WENNERSTEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:608 TIMBER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-4303
Mailing Address - Country:US
Mailing Address - Phone:405-818-3559
Mailing Address - Fax:
Practice Address - Street 1:3300 NW EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4418
Practice Address - Country:US
Practice Address - Phone:405-942-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22166980363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care