Basic Information
| Provider Information | |||||||||
| NPI: | 1598779266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANTZLER | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 STRAKA TER | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731392544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056326688 | ||||||||
| FaxNumber: | 4056040708 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 W. MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TIPTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5806674149 | ||||||||
| FaxNumber: | 5806674166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R0048099 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200051130A | 05 | OK | MEDICAID |