Basic Information
| Provider Information | |||||||||
| NPI: | 1700875598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENLOW | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAGSDALE | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | LYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1203 E ROSS BYP STE A | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744644158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184531234 | ||||||||
| FaxNumber: | 9184539107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1203 E ROSS BYP | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184531234 | ||||||||
| FaxNumber: | 9184539107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 06/04/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R0067005 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200000030A | 01 | OK | MEDICAID GROUP NUMBER | OTHER | P00399872 | 01 | OK | RAILROAD MEDICARE PIN NUMBER | OTHER | 200073760A | 05 | OK | MEDICAID | 400522239 | 01 | OK | MEDICARE GROUP PTAN | OTHER | DA5295 | 01 | OK | RAILROAD MEDICARE GROUP NUMBER | OTHER |