Provider Demographics
NPI:1154719169
Name:MAIN STREET FAMILY HEALTHCARE NURSE PRACTITIONER CLINIC, LLC
Entity type:Organization
Organization Name:MAIN STREET FAMILY HEALTHCARE NURSE PRACTITIONER CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRONWYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP
Authorized Official - Phone:918-950-5053
Mailing Address - Street 1:309 W MAIN ST
Mailing Address - Street 2:P.O. BOX 968
Mailing Address - City:STROUD
Mailing Address - State:OK
Mailing Address - Zip Code:74079-3611
Mailing Address - Country:US
Mailing Address - Phone:918-987-0067
Mailing Address - Fax:
Practice Address - Street 1:309 W MAIN ST
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-3611
Practice Address - Country:US
Practice Address - Phone:918-987-0067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-27
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0052024261QP2300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200121770AMedicaid
OK2005513360AMedicaid
OK2005513360AMedicaid