Healthcare Provider Details

I. General information

NPI: 1578065777
Provider Name (Legal Business Name): TRACEY SUZANNE DUDLEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 02/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3613 NW 56TH ST STE 150
OKLAHOMA CITY OK
73112-4506
US

IV. Provider business mailing address

2911 NW 17TH ST
OKLAHOMA CITY OK
73107-3901
US

V. Phone/Fax

Practice location:
  • Phone: 405-600-1210
  • Fax:
Mailing address:
  • Phone: 405-226-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number101402
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101402
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: