Provider Demographics
NPI:1619965662
Name:JEFFERSON, NANCY A (NP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 E 97TH PL
Mailing Address - Street 2:APT 1201
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-7309
Mailing Address - Country:US
Mailing Address - Phone:918-296-9477
Mailing Address - Fax:918-748-1303
Practice Address - Street 1:1717A S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5344
Practice Address - Country:US
Practice Address - Phone:918-748-1300
Practice Address - Fax:918-748-1303
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0059141363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200039750AMedicaid
Q30585Medicare UPIN
OK248502706Medicare ID - Type Unspecified
OK200039750AMedicaid