Healthcare Provider Details

I. General information

NPI: 1336982511
Provider Name (Legal Business Name): ALYSON N. MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W 17TH ST
TULSA OK
74107-1886
US

IV. Provider business mailing address

533 S CHEROKEE AVE
TAHLEQUAH OK
74464-4405
US

V. Phone/Fax

Practice location:
  • Phone: 918-582-1972
  • Fax:
Mailing address:
  • Phone: 405-595-1797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: