Healthcare Provider Details

I. General information

NPI: 1508393042
Provider Name (Legal Business Name): TRACI DAWN GILLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI DAWN WILSON RN

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 05/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E MAIN ST
NORMAN OK
73071-5305
US

IV. Provider business mailing address

407 N TAYLOR AVE
WYNNEWOOD OK
73098-4630
US

V. Phone/Fax

Practice location:
  • Phone: 405-307-4839
  • Fax:
Mailing address:
  • Phone: 903-818-3663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number0119242
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: