Basic Information
| Provider Information | |||||||||
| NPI: | 1902103492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAREN | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | DION | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 720006 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055336057 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1027 E CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | CUSHING | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740234101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182258378 | ||||||||
| FaxNumber: | 9182251291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2011 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
| 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 | 363LF0000X | 79453 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | R0079453 | 01 | OK | LICENSE | OTHER | 200097040A | 05 | OK | MEDICAID |