Provider Demographics
NPI:1922508266
Name:CASTLEBERRY, CODI NICOLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:CODI
Middle Name:NICOLE
Last Name:CASTLEBERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11426 N 134TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4715
Mailing Address - Country:US
Mailing Address - Phone:918-376-6345
Mailing Address - Fax:
Practice Address - Street 1:11426 N 134TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4715
Practice Address - Country:US
Practice Address - Phone:918-376-6345
Practice Address - Fax:918-376-6635
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2891363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant