MEDICARE: MARIA GABRIELLA PRUDHOMME NP

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	363L00000X	Nurse Practitioner	RN213432	GA
2	363L00000X	Nurse Practitioner	1067064	TX
3	363LF0000X	Family Nurse Practitioner	RN213432	GA
4	363LF0000X	Family Nurse Practitioner	1067064	TX
5	363LF0000X	Family Nurse Practitioner	210652	OK

General Provider Information

NPI Number	:	1710396718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA GABRIELLA PRUDHOMME NP

Provider Business Mailing Address
First Line	:	1000 NE 13TH ST STE 1C
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-5040
Country	:	US
Telephone Number	:	405-271-5992
Fax Number	:	405-271-5992

Provider Business Practice Location Address
First Line	:	1000 NE 13TH ST # 1C
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-5040
Country	:	US
Telephone Number	:	405-271-6110
Fax Number	:

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

Provider Enumeration Date	:	08/05/2014
Last Update Date	:	03/21/2023

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