Provider Demographics
NPI:1104691120
Name:DRYWATER, RITA M
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:M
Last Name:DRYWATER
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 1:215 N FAIRLAND ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4207
Mailing Address - Country:US
Mailing Address - Phone:918-373-8003
Mailing Address - Fax:
Practice Address - Street 1:215 N FAIRLAND ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4207
Practice Address - Country:US
Practice Address - Phone:918-373-8003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0025316164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse