Healthcare Provider Details

I. General information

NPI: 1184586125
Provider Name (Legal Business Name): NEW IDENTITY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2025
Last Update Date: 11/28/2025
Certification Date: 11/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 NW 117TH ST
OKLAHOMA CITY OK
73114-7922
US

IV. Provider business mailing address

1211 PINE VLY
EDMOND OK
73012-4364
US

V. Phone/Fax

Practice location:
  • Phone: 405-824-1378
  • Fax:
Mailing address:
  • Phone: 405-824-1378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number
License Number State

VIII. Authorized Official

Name: MONICA A. TUCKER
Title or Position: RN ADMINISTRATION
Credential: RN
Phone: 405-824-1378