Individual
MRS. MARY ILLIG MINIELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
8100 S. WALKER AVENUE, BUILDING A, OKLAHOMA CITY, OK 73139-9404
(405) 632-4468
(405) 631-4964
Mailing address
8100 S. WALKER AVENUE, BUILDING A, OKLAHOMA CITY, OK 73139-9404
(405) 632-4468
(405) 631-4964
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
R0059137
OK
363LA2100X
Acute Care Nurse Practitioner
R0059137
OK
Other
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
Enumeration date
03/05/2007
Last updated
03/07/2023
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