Healthcare Provider Details

I. General information

NPI: 1063258200
Provider Name (Legal Business Name): VICTORA M CONWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32300 S 625 RD
GROVE OK
74344-6285
US

IV. Provider business mailing address

PO BOX 451585
GROVE OK
74345-1585
US

V. Phone/Fax

Practice location:
  • Phone: 918-787-2242
  • Fax:
Mailing address:
  • Phone: 918-787-2242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: