Provider Demographics
NPI:1104054147
Name:PORCH-PETITT, LISHA RYANNE (CNS)
Entity type:Individual
Prefix:
First Name:LISHA
Middle Name:RYANNE
Last Name:PORCH-PETITT
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N HARVARD AVE
Mailing Address - Street 2:STE E
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-4957
Mailing Address - Country:US
Mailing Address - Phone:918-832-6049
Mailing Address - Fax:
Practice Address - Street 1:2000 S WHEELING AVE
Practice Address - Street 2:STE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5649
Practice Address - Country:US
Practice Address - Phone:918-748-7854
Practice Address - Fax:918-293-3116
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0058269364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist