=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447868849
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMMIE LADAWN WYCKOFF RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2020
-----------------------------------------------------
Last Update Date | 07/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 COOKSON DR
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74604-4109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-977-8684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 COOKSON DR
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74604-4109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-977-8684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | R0071717
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------