Provider Demographics
NPI:1912286428
Name:BATES, ELIZABETH ANN (LPN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:BATES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 TIMOTHY LN
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:OK
Mailing Address - Zip Code:74730-5122
Mailing Address - Country:US
Mailing Address - Phone:580-212-5216
Mailing Address - Fax:
Practice Address - Street 1:5912 HIGHWAY 70 E
Practice Address - Street 2:
Practice Address - City:MEAD
Practice Address - State:OK
Practice Address - Zip Code:73449
Practice Address - Country:US
Practice Address - Phone:580-745-9083
Practice Address - Fax:580-745-9885
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58621164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid