Provider Demographics
NPI:1386694107
Name:CARLISLE, CARLEEN D (ARNP)
Entity type:Individual
Prefix:
First Name:CARLEEN
Middle Name:D
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 S UTICA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5346
Mailing Address - Country:US
Mailing Address - Phone:918-748-7557
Mailing Address - Fax:918-403-0383
Practice Address - Street 1:1717 S UTICA AVE STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5346
Practice Address - Country:US
Practice Address - Phone:918-748-7557
Practice Address - Fax:918-403-0383
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0076525363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200036720AMedicaid
OK200036720BMedicaid