# MRS. MARY ILLIG MINIELLY

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1417086380
- **Gender:** F
- **Credential:** APRN

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363L00000X | Nurse Practitioner | R0059137 | OK | Yes |
| 363LA2100X | Acute Care Nurse Practitioner | R0059137 | OK | — |

## Other

- **Enumeration date:** 03/05/2007
- **Last updated:** 03/07/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 100130740A | OHCA | OK |
| 01 | — | 12317438 | CAQH | OK |
| 01 | — | 1417086380 | NPI | OK |
| 01 | — | 28812 | ONBDD | OK |
| 01 | — | 59137 | LICENSE | OK |