Provider Demographics
NPI:1659748556
Name:OLD TYME HOME VISITS LLC
Entity Type:Organization
Organization Name:OLD TYME HOME VISITS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCED PRACTICE NURSE / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWBRE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP-CNP
Authorized Official - Phone:405-527-4704
Mailing Address - Street 1:128 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-4220
Mailing Address - Country:US
Mailing Address - Phone:405-527-4704
Mailing Address - Fax:405-527-5976
Practice Address - Street 1:128 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-4220
Practice Address - Country:US
Practice Address - Phone:405-527-4704
Practice Address - Fax:405-527-5976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK49456363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty