Provider Demographics
NPI:1740063577
Name:LETHERMON, MATTIE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:LETHERMON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4937 S QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-4730
Mailing Address - Country:US
Mailing Address - Phone:620-515-4814
Mailing Address - Fax:
Practice Address - Street 1:1220 N FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-4381
Practice Address - Country:US
Practice Address - Phone:918-341-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK214829363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care