Healthcare Provider Details

I. General information

NPI: 1154486629
Provider Name (Legal Business Name): GRETCHEN MICHELLE BEAGLES CCP LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 N MAY AVE SUITE C
OKLAHOMA CITY OK
73112-6641
US

IV. Provider business mailing address

PO BOX 12815
OKLAHOMA CITY OK
73157-2815
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-5613
  • Fax: 405-601-3750
Mailing address:
  • Phone: 405-604-5613
  • Fax: 405-601-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberLP63
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License NumberLP63
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: