Healthcare Provider Details

I. General information

NPI: 1477025658
Provider Name (Legal Business Name): GRACE DPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 S GRAND AVE
CHEROKEE OK
73728-2029
US

IV. Provider business mailing address

221 S GRAND AVE
CHEROKEE OK
73728-2029
US

V. Phone/Fax

Practice location:
  • Phone: 580-307-6263
  • Fax: 580-603-8602
Mailing address:
  • Phone: 580-307-6263
  • Fax: 580-603-8602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NIKI LEWIS-WYATT
Title or Position: PRESIDENT
Credential: PA-C
Phone: 580-307-6263