Provider Demographics
NPI:1992388284
Name:ZUMWALT, NICHOLAS L (RN)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:L
Last Name:ZUMWALT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 S CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-1461
Mailing Address - Country:US
Mailing Address - Phone:918-760-2853
Mailing Address - Fax:
Practice Address - Street 1:4623 W KENOSHA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8975
Practice Address - Country:US
Practice Address - Phone:918-461-0422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK204532363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily