Provider Demographics
NPI:1902281777
Name:CRUZ, JEANETTE
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73078-0660
Mailing Address - Country:US
Mailing Address - Phone:405-373-2400
Mailing Address - Fax:
Practice Address - Street 1:11109 SURREY HILLS BLVD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-8155
Practice Address - Country:US
Practice Address - Phone:405-373-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK82129282N00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK439590YNM8Medicaid