MEDICARE: MRS. VICKI RENEE THREADGILL APRN NNP BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LN0005X	Critical Care Neonatal Nurse Practitioner	1217913	TX
2	363LN0005X	Critical Care Neonatal Nurse Practitioner	C-APN0106198	CO
3	363LN0005X	Critical Care Neonatal Nurse Practitioner	52055	OK

General Provider Information

NPI Number	:	1194090134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VICKI RENEE THREADGILL APRN NNP BC

Provider Business Mailing Address
First Line	:	5300 N INDEPENDENCE AVE
Second Line	:	SUITE 280
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-5556
Country	:	US
Telephone Number	:	405-949-3393
Fax Number	:	405-945-5493

Provider Business Practice Location Address
First Line	:	3300 NW EXPRESSWAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4418
Country	:	US
Telephone Number	:	405-949-3393
Fax Number	:	405-945-5493

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2012
Last Update Date	:	03/26/2026

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