Healthcare Provider Details

I. General information

NPI: 1639060171
Provider Name (Legal Business Name): MICHELLE DIANE WILLIS APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE DIANE WILSON

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W GRAND AVE
CHICKASHA OK
73018-5862
US

IV. Provider business mailing address

4133 BLUE RIDGE AVE
NORMAN OK
73072-4043
US

V. Phone/Fax

Practice location:
  • Phone: 405-224-0053
  • Fax:
Mailing address:
  • Phone: 405-613-8538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number224385
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number224385
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: