Healthcare Provider Details

I. General information

NPI: 1245350172
Provider Name (Legal Business Name): SANDRA V WALLACE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 ALAMEDA ST
NORMAN OK
73071-5229
US

IV. Provider business mailing address

1628 ORIOLE DR
NORMAN OK
73071-6127
US

V. Phone/Fax

Practice location:
  • Phone: 405-573-3909
  • Fax: 405-573-3966
Mailing address:
  • Phone: 405-321-7610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR0047895 D6361633
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: