Healthcare Provider Details

I. General information

NPI: 1154661429
Provider Name (Legal Business Name): COURTNEY RENEE WYLIE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COURTNEY RENEE FORD DO

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HEALTH CENTER PKWY
YUKON OK
73099-6381
US

IV. Provider business mailing address

1427 E 35TH ST
TULSA OK
74105
US

V. Phone/Fax

Practice location:
  • Phone: 405-717-6800
  • Fax: 405-717-7964
Mailing address:
  • Phone: 918-399-2449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5649
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: