Healthcare Provider Details

I. General information

NPI: 1346235488
Provider Name (Legal Business Name): JACQUELINE L GILLESPIE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 W ELK AVE
DUNCAN OK
73533-1562
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 580-252-9600
  • Fax: 580-252-6100
Mailing address:
  • Phone: 605-312-7605
  • Fax: 605-312-7611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberR0045906
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number45906
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: