Provider Demographics
NPI:1366904740
Name:BLOXHAM, LISA ANN (APRN-CNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BLOXHAM
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 W KNOXVILLE ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4657
Mailing Address - Country:US
Mailing Address - Phone:918-645-9411
Mailing Address - Fax:
Practice Address - Street 1:12697 E 51ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-6236
Practice Address - Country:US
Practice Address - Phone:918-505-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0099475163WX0200X
OK99475363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WX0200XNursing Service ProvidersRegistered NurseOncology