Provider Demographics
NPI:1750050456
Name:PICKLE, TAWNA LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:TAWNA
Middle Name:LYNN
Last Name:PICKLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-5833
Mailing Address - Country:US
Mailing Address - Phone:405-757-7818
Mailing Address - Fax:
Practice Address - Street 1:400 N EASTERN AVE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5833
Practice Address - Country:US
Practice Address - Phone:405-757-7818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK205330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty