Healthcare Provider Details

I. General information

NPI: 1225434756
Provider Name (Legal Business Name): PHYLLIS A. PEACE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 11/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12455 E 100TH ST N STE 300
OWASSO OK
74055-4678
US

IV. Provider business mailing address

12455 E 100TH ST N STE 300
OWASSO OK
74055-4678
US

V. Phone/Fax

Practice location:
  • Phone: 918-274-9700
  • Fax: 918-274-1395
Mailing address:
  • Phone: 918-274-9700
  • Fax: 918-274-1395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number79303
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: