Healthcare Provider Details

I. General information

NPI: 1205408481
Provider Name (Legal Business Name): RIVER WOLF GYNECOLOGY & FAMILY HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 BANBURY LN
OKLAHOMA CITY OK
73170-3401
US

IV. Provider business mailing address

2104 BANBURY LN
OKLAHOMA CITY OK
73170-3401
US

V. Phone/Fax

Practice location:
  • Phone: 405-203-5382
  • Fax:
Mailing address:
  • Phone: 405-203-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KALLI WOLF
Title or Position: OWNER, CLINICIAN
Credential: CNM, FNP-C
Phone: 405-203-5382