Provider Demographics
NPI:1942286133
Name:WELLS, JAN ELLEN (ARNP)
Entity type:Individual
Prefix:MS
First Name:JAN
Middle Name:ELLEN
Last Name:WELLS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:109 N FAIRLAND ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4203
Mailing Address - Country:US
Mailing Address - Phone:918-824-4424
Mailing Address - Fax:918-824-4474
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4203
Practice Address - Country:US
Practice Address - Phone:918-824-4424
Practice Address - Fax:918-824-4474
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0027163363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100094230Medicaid
OK100094230Medicaid
OKS60387Medicare UPIN