Healthcare Provider Details

I. General information

NPI: 1043714587
Provider Name (Legal Business Name): TRACY LEE FOSTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 07/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10512 N 110TH EAST AVE
OWASSO OK
74055
US

IV. Provider business mailing address

10512 N 110TH EAST AVE
OWASSO OK
74055-6636
US

V. Phone/Fax

Practice location:
  • Phone: 918-376-8410
  • Fax:
Mailing address:
  • Phone: 918-289-3945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number66957
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number66957
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: