Provider Demographics
NPI:1982991519
Name:ELITE RN PC
Entity type:Organization
Organization Name:ELITE RN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:ETTER
Authorized Official - Suffix:
Authorized Official - Credentials:CCNSRX
Authorized Official - Phone:580-402-1635
Mailing Address - Street 1:PO BOX 3031
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73702-3031
Mailing Address - Country:US
Mailing Address - Phone:580-237-2327
Mailing Address - Fax:580-237-2339
Practice Address - Street 1:3568 MCCLAFLIN DR
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-7745
Practice Address - Country:US
Practice Address - Phone:580-402-1635
Practice Address - Fax:580-233-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-04
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK50268364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200281660AMedicaid