NPIMap

Lista Marie Dallis

Individual provider Active NPI Family Nurse Practitioner · Tahlequah, OK

NPI 1104468610 · NPPES record last updated Feb 17, 2022

Key facts

NPI
1104468610
Entity type
Individual (NPI type 1)
Primary specialty
Family Nurse Practitioner 363LF0000X
License
99753 (OK)
Practice address
1500 E Downing St Ste 214
Tahlequah, OK 74464-3379
Phone
(918) 413-0202
Fax
(918) 431-0203
NPI assigned
Oct 16, 2019
Sex
Female
Sole proprietor
No

Organizations & group practices 15

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

Medicare Care Compare profile

Specialty
Nurse Practitioner
Education
Other, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Northeastern Oklahoma Community Health Centers, Inc (38 clinicians)

Practice addresses (Care Compare)

1500 E Downing St
Suite 214
Tahlequah, OK 74464-3379
Phone (918) 431-0202

Hospital & facility affiliations

  • Northeastern Health System Hospital · Tahlequah, OK · CCN 370089

Medicare participation

Medicare fee-for-service enrollment
Enrolled in OK
Eligible to order & refer
Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
I20200203000406 OK Practitioner - Nurse Practitioner 9032545595 Reassigns benefits to 1 organization

National Provider Directory

Medicare enrollment (NPD)
Yes
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
99753OKMDFamily Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Northeastern Oklahoma Community Health Centers Inc Current
since Dec 1, 2019		 Accepting new patients
Northeastern Oklahoma Community Health Centers, Inc Current
since Dec 1, 2019		 Accepting new patients
Northeastern Oklahoma Community Health Centers Inc Current Accepting new patients
Northeastern Health System Past Accepting new patients
Northeastern Health System Past Accepting new patients
Northeastern Oklahoma Community Health Centers, Inc Past Accepting new patients

Locations

124 E Main St
Hulbert, OK 74441
Phone (918) 772-2879

922 N York St
Muskogee, OK 74403
Phone (918) 683-0470

1500 E Downing St
Ste 101
Tahlequah, OK 74464
Phone (918) 456-2549

1500 E Downing St
Ste 214
Tahlequah, OK 74464
Phone (918) 413-0202

1500 E Downing St
Ste 201
Tahlequah, OK 74464
Phone (918) 772-3390

Interoperability endpoints

  • FHIR API: https://fhir-myrecord.cerner.com/r4/932b43fb-c766-413c-a343-640549d20cb3/

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X 99753 OK Yes

Addresses

Primary practice location

1500 E Downing St Ste 214
Tahlequah, OK 74464-3379

Mailing address

PO Box 751
Hulbert, OK 74441-0751
Phone (187) 723-3990

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Feb 17, 2022.

{
    "created_epoch": "1571184000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1645056000000",
    "number": "1104468610",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 751",
            "city": "HULBERT",
            "state": "OK",
            "postal_code": "744410751",
            "telephone_number": "187-723-3990",
            "fax_number": "918-772-3638"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 E DOWNING ST STE 214",
            "city": "TAHLEQUAH",
            "state": "OK",
            "postal_code": "744643379",
            "telephone_number": "918-413-0202",
            "fax_number": "918-431-0203"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DALLIS",
        "first_name": "LISTA",
        "middle_name": "MARIE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-10-16",
        "last_updated": "2022-02-17",
        "certification_date": "2022-02-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "OK",
            "license": "99753",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tahlequah, OK

All providers in Tahlequah, OK · Family Nurse Practitioner in Oklahoma

Sources for this page

Verify at the official NPI Registry.