Individual
MRS. PHYLLIS A WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
527 W 3RD ST, KONAWA, OK 74849-1415
(580) 925-3286
(580) 925-9149
Mailing address
527 W 3RD ST, KONAWA, OK 74849-1415
(580) 925-3286
(580) 925-9149
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
35497
OK
363LW0102X
Women's Health Nurse Practitioner
R0035497
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100155800A
—
OK
01
—
100155800B
SOONERCARE PROVIDER
OK
Enumeration date
06/16/2006
Last updated
11/22/2021
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