Provider Demographics
NPI:1700875598
Name:ENLOW, LORI LYN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LYN
Last Name:ENLOW
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:LYN
Other - Last Name:RAGSDALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1203 E ROSS BYP STE A
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4158
Mailing Address - Country:US
Mailing Address - Phone:918-453-1234
Mailing Address - Fax:918-453-9107
Practice Address - Street 1:1203 E ROSS BYP
Practice Address - Street 2:SUITE A
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-453-1234
Practice Address - Fax:918-453-9107
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0067005363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200000030AOtherMEDICAID GROUP NUMBER
OKP00399872OtherRAILROAD MEDICARE PIN NUMBER
OK200073760AMedicaid
OK400522239OtherMEDICARE GROUP PTAN
OKDA5295OtherRAILROAD MEDICARE GROUP NUMBER
OKP66449Medicare UPIN
OK243604603Medicare PIN