=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184586125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW IDENTITY FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2025
-----------------------------------------------------
Last Update Date | 11/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 NW 117TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73114-7922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-824-1378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1211 PINE VLY
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73012-4364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-824-1378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RN ADMINISTRATION
-----------------------------------------------------
Name | MONICA A. TUCKER
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 405-824-1378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WA2000X
-----------------------------------------------------
Taxonomy Name | Administrator Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC0400X
-----------------------------------------------------
Taxonomy Name | Case Management Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 163WM1400X
-----------------------------------------------------
Taxonomy Name | Nurse Massage Therapist (NMT)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------