=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346841673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NUGENEX PLUS APRN-CNP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2020
-----------------------------------------------------
Last Update Date | 06/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2524 N BROADWAY STE 314
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-4172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-256-3361
-----------------------------------------------------
Fax | 801-806-5401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13425 DEER SPRING DR
-----------------------------------------------------
City | PIEDMONT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73078-3001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-999-3667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TRACI LAMBERT
-----------------------------------------------------
Credential | APRN-CNP
-----------------------------------------------------
Telephone | 405-999-3667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------