Provider Demographics
NPI:1972265981
Name:WAGENBLATT, KARISSA MCNEAL (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:MCNEAL
Last Name:WAGENBLATT
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3333
Mailing Address - Country:US
Mailing Address - Phone:918-488-6653
Mailing Address - Fax:918-488-6098
Practice Address - Street 1:10506 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6914
Practice Address - Country:US
Practice Address - Phone:918-369-3200
Practice Address - Fax:918-369-3209
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK205796363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily