=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659078129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY GRACE DIFUNTORUM APRN, FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2023
-----------------------------------------------------
Last Update Date | 02/20/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 N EASTERN AVE
-----------------------------------------------------
City | MOORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73160-5833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-730-6990
-----------------------------------------------------
Fax | 405-730-6992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 891625
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73189-1625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 210920
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------