Provider Demographics
NPI:1184166753
Name:HANTAK, JACINDA (APRN-CNP)
Entity type:Individual
Prefix:
First Name:JACINDA
Middle Name:
Last Name:HANTAK
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 1:4400 GRANT BLVD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-0037
Mailing Address - Country:US
Mailing Address - Phone:405-603-4660
Mailing Address - Fax:
Practice Address - Street 1:4400 GRANT BLVD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-0037
Practice Address - Country:US
Practice Address - Phone:405-603-4660
Practice Address - Fax:405-470-3377
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-13
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK96351363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily