Healthcare Provider Details

I. General information

NPI: 1447623509
Provider Name (Legal Business Name): MACKENZIE NICOLE TUTTY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACKENZIE NICOLE HIEGER

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7858 S OLYMPIA AVE
TULSA OK
74132-1857
US

IV. Provider business mailing address

6600 S YALE AVE STE 1400
TULSA OK
74136-3331
US

V. Phone/Fax

Practice location:
  • Phone: 918-986-9250
  • Fax: 918-986-9205
Mailing address:
  • Phone: 888-247-0125
  • Fax: 918-502-8210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2600
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: