Provider Demographics
NPI:1811321102
Name:MAIN STREET FAMILY CLINIC APRN-CNP PLLC
Entity type:Organization
Organization Name:MAIN STREET FAMILY CLINIC APRN-CNP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:BEISTLE
Authorized Official - Last Name:SCHROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP
Authorized Official - Phone:918-518-5770
Mailing Address - Street 1:1201 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2311
Mailing Address - Country:US
Mailing Address - Phone:918-518-5770
Mailing Address - Fax:918-518-5773
Practice Address - Street 1:1201 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2311
Practice Address - Country:US
Practice Address - Phone:918-518-5770
Practice Address - Fax:918-518-5773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR00035175261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care