Healthcare Provider Details

I. General information

NPI: 1104143213
Provider Name (Legal Business Name): TRACY LEIGH WILDE BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY LEIGH BIGBY BA

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7015 S DOGWOOD PL
BROKEN ARROW OK
74011-2071
US

IV. Provider business mailing address

7015 S DOGWOOD PL
BROKEN ARROW OK
74011-2071
US

V. Phone/Fax

Practice location:
  • Phone: 918-630-3566
  • Fax:
Mailing address:
  • Phone: 918-630-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: