Healthcare Provider Details

I. General information

NPI: 1437953908
Provider Name (Legal Business Name): MRS. CASIE WALLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9103 E 510 RD
CLAREMORE OK
74019-0865
US

IV. Provider business mailing address

9103 E 510 RD
CLAREMORE OK
74019-0865
US

V. Phone/Fax

Practice location:
  • Phone: 918-289-7139
  • Fax:
Mailing address:
  • Phone: 918-289-7139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number216647
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: