Provider Demographics
NPI:1619298346
Name:CUPP, NICOLE LYNN (DPM)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LYNN
Last Name:CUPP
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 SE DEBELL AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2343
Mailing Address - Country:US
Mailing Address - Phone:918-876-0476
Mailing Address - Fax:918-876-0479
Practice Address - Street 1:226 SE DEBELL AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2343
Practice Address - Country:US
Practice Address - Phone:918-876-0476
Practice Address - Fax:918-876-0479
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK301213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200526540AMedicaid
OK200526540AMedicaid