Healthcare Provider Details

I. General information

NPI: 1588537872
Provider Name (Legal Business Name): AUTUMN DETRICK APRN-CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W MEMORIAL RD STE 901
OKLAHOMA CITY OK
73120-8378
US

IV. Provider business mailing address

4200 W MEMORIAL RD STE 901
OKLAHOMA CITY OK
73120-8378
US

V. Phone/Fax

Practice location:
  • Phone: 405-242-4030
  • Fax: 405-242-4031
Mailing address:
  • Phone: 405-242-4030
  • Fax: 405-242-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number217320
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: