Provider Demographics
NPI:1154152403
Name:TITSWORTH, DALE WAYNE (NP)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:WAYNE
Last Name:TITSWORTH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 NE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7937
Mailing Address - Country:US
Mailing Address - Phone:405-496-4783
Mailing Address - Fax:
Practice Address - Street 1:4140 W MEMORIAL RD STE 518
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8300
Practice Address - Country:US
Practice Address - Phone:405-749-4230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK219785363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily