Individual
NICOLE LISETTE MANCINELLI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
2424 E. 21ST STREET, SUITE 320, TULSA, OK 74114
(918) 392-4547
(918) 392-4555
Mailing address
2909 E 97TH CT, APT. 2212, TULSA, OK 74137-7435
(918) 392-4547
(918) 392-4555
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
2195
OK
363AS0400X
Surgical Physician Assistant
Primary
2195
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200474170A
—
OK
Enumeration date
02/01/2013
Last updated
09/14/2016
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