Basic Information
| Provider Information | |||||||||
| NPI: | 1982991519 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELITE RN PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3031 | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737023031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802372327 | ||||||||
| FaxNumber: | 5802372339 | ||||||||
| Practice Location | |||||||||
| Address1: | 3568 MCCLAFLIN DR | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737017745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804021635 | ||||||||
| FaxNumber: | 5802332131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2011 | ||||||||
| LastUpdateDate: | 07/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | ETTER | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | JEANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5804021635 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CCNSRX | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2100X | 50268 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 200281660A | 05 | OK | MEDICAID |