Provider Demographics
NPI:1740578103
Name:TUPPER, DIANNE GENENE (RN, OPA-C)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:GENENE
Last Name:TUPPER
Suffix:
Gender:F
Credentials:RN, OPA-C
Other - Prefix:MS
Other - First Name:DIANNE
Other - Middle Name:GENENE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, OPA-C
Mailing Address - Street 1:175 LARY LN
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-6542
Mailing Address - Country:US
Mailing Address - Phone:405-742-8898
Mailing Address - Fax:
Practice Address - Street 1:12301 N WESTERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-8017
Practice Address - Country:US
Practice Address - Phone:405-757-8338
Practice Address - Fax:405-715-7179
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0083080163WX0800X
OK83080163WX0800X
OK1148363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No163WX0800XNursing Service ProvidersRegistered NurseOrthopedic
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical