MEDICARE: TRACEY SUZANNE DUDLEY APRN

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	364SP0200X	Pediatric Clinical Nurse Specialist	101402	OK
2	363LF0000X	Family Nurse Practitioner	101402	OK

General Provider Information

NPI Number	:	1578065777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY SUZANNE DUDLEY APRN

Provider Business Mailing Address
First Line	:	2911 NW 17TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-3901
Country	:	US
Telephone Number	:	405-226-6513
Fax Number	:

Provider Business Practice Location Address
First Line	:	3613 NW 56TH ST STE 150
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4506
Country	:	US
Telephone Number	:	405-600-1210
Fax Number	:

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

Provider Enumeration Date	:	03/02/2018
Last Update Date	:	02/03/2019

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Directions to “ TRACEY SUZANNE DUDLEY APRN” Practice Location

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