Healthcare Provider Details

I. General information

NPI: 1760347728
Provider Name (Legal Business Name): SHAUNI RENEE VICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2025
Last Update Date: 12/22/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 E OMAHA ST
BROKEN ARROW OK
74012-0361
US

IV. Provider business mailing address

1721 E OMAHA ST
BROKEN ARROW OK
74012-0361
US

V. Phone/Fax

Practice location:
  • Phone: 918-699-9184
  • Fax:
Mailing address:
  • Phone: 918-699-9184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: