Healthcare Provider Details

I. General information

NPI: 1740447606
Provider Name (Legal Business Name): VICKI GRACE YACKEYONNY RMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICKI GRACE JEMISON RMA

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4913 W RENO AVE
OKLAHOMA CITY OK
73127-6339
US

IV. Provider business mailing address

4913 W RENO AVE
OKLAHOMA CITY OK
73127-6339
US

V. Phone/Fax

Practice location:
  • Phone: 405-948-4900
  • Fax: 405-948-4934
Mailing address:
  • Phone: 405-948-4900
  • Fax: 405-948-4934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: