Basic Information
| Provider Information | |||||||||
| NPI: | 1134607310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLASS | ||||||||
| FirstName: | SHANNA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 W 6TH AVE STE 207 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055333010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1301 W 6TH AVE STE 207 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055333010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2018 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 79263 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.