MRS. PHYLLIS A WALLACE (NPI# 1366486417) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1366486417 |
| Entity Type | Individual |
| Full Name | MRS. PHYLLIS A WALLACE |
| Credential | APRN |
| Practice Address |
527 W 3rd St Konawa OK 74849-1415 |
| Practice Telephone | 5809253286 |
| Practice Fax Number | 5809259149 |
| Mailing Telephone | 5809253286 |
| Mailing Fax Number | 5809259149 |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2015-04-01 |
| Gender Code | F |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 363LF0000X |
Nurse Practitioner Specialization: Family |
35497 | OK | Physician Assistants & Advanced Practice Nursing Providers |
| Y | 363LW0102X |
Nurse Practitioner Specialization: Women's Health |
R0035497 | OK | Physician Assistants & Advanced Practice Nursing Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| OK | 100155800A | 05 | |
| OK | SOONERCARE PROVIDER | 100155800B | 01 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1679708556 | Phyllis Marie Wallace | Registered Nurse | 6560 Fannin St, Suite 600, Houston, TX 77030-2761 | 2009-05-21 |
| Street Address |
527 W 3RD ST |
| City | KONAWA |
| State | OK |
| Zip Code | 74849-1415 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1962407999 | Judy Pearce | Nurse Practitioner | 527 W 3rd St, Konawa, OK 74849-1415 | 2005-06-16 |
| 1366049280 | Kelsey Katherine Hartman | Physician Assistant | 527 W 3rd St, Konawa, OK 74849-1415 | 2020-10-04 |
| 1548886831 | Kelli Lowry | Speech-Language Pathologist | 527 W 3rd St, Konawa, OK 74849-1415 | 2020-06-22 |
| 1407414295 | Roberto Bonilla Gallegos | Case Manager/Care Coordinator | 527 W 3rd St, Konawa, OK 74849-1415 | 2019-06-05 |
| 1750882775 | Amanda Lynn Cubit | Nurse Practitioner | 527 W 3rd St, Konawa, OK 74849-1415 | 2018-02-25 |
| 1376061127 | Cari Renee Gravel | Social Worker | 527 W 3rd St, Konawa, OK 74849-1415 | 2017-08-31 |
| 1235659418 | Marilyn Kay Dixon | Case Manager/Care Coordinator | 527 W 3rd St, Konawa, OK 74849-1415 | 2017-06-20 |
| 1881067502 | Paige Vandegrift | Social Worker | 527 W 3rd St, Konawa, OK 74849-1415 | 2015-11-03 |
| 1285013540 | Central Oklahoma Family Medical Center, Inc | Specialist | 527 W 3rd St, Konawa, OK 74849-1415 | 2015-05-20 |
| 1255767372 | Lindsey Clark | Social Worker | 527 W 3rd St, Konawa, OK 74849-1415 | 2013-09-20 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1548680176 | Dave Garrett Herriman | Social Worker | 527 W Third Street, Konawa, OK 74849 | 2014-04-22 |
| 1518152529 | Tami Ranae Hernandez | Counselor | 527 West Third St, Konawa, OK 74849 | 2007-09-12 |
| 1427067859 | Erron Cody Proctor | Physician Assistant | 527 West 3rd St, Konawa, OK 74849 | 2006-08-05 |
| 1972519544 | Umar Saeed | Family Medicine | 527 West Third Street, Konawa, OK 74849 | 2006-08-01 |
| 1831291293 | Central Oklahoma Family Medical Center, Inc. | Clinic/Center | 527 West 3rd St, Konawa, OK 74849 | 2006-09-05 |
| 1972725828 | Larna Louise Tribbey | Counselor | 527 West Third Street, Konawa, OK 74849-0000 | 2007-05-02 |
| 1104315829 | Konawa Public Schools | Local Education Agency (LEA) | 701 W South St, Konawa, OK 74849-1417 | 2018-05-08 |
| 1932482957 | Doris Chance | Case Manager/Care Coordinator | 308 W 4th St, Konawa, OK 74849-1612 | 2011-09-26 |
| 1922137314 | Cbw Inc | Intermediate Care Facility, Mental Illness | 308 W 4th St, Konawa, OK 74849-1612 | 2007-03-03 |
| 1255538237 | Gayla Carter | Counselor | 316 N East St, Konawa, OK 74849-1802 | 2007-07-02 |
| Find all providers in zip 74849 | ||||
| Taxonomy Code | 363LW0102X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Nurse Practitioner |
| Specialization | Women's Health |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1831729920 | Sheila Metzger | Nurse Practitioner | 2550 W Franklin Rd, Norman, OK 73069-8012 | 2020-01-17 |
| 1295380269 | Meisha Hall | Nurse Practitioner | 2508 W Huntsville St, Broken Arrow, OK 74011-6124 | 2019-08-07 |
| 1851896237 | Leslie King | Nurse Practitioner | 4809 East 89th Street South, Suite 100, Tulsa, OK 74137 | 2018-03-27 |
| 1437695715 | Erika Rumble | Nurse Practitioner | 10901 E 48th Street S, Tulsa, OK 74146-5830 | 2017-01-11 |
| 1083073365 | Kendra Seccombe | Nurse Practitioner | 161 Eco Friendly Dr, Suite 201, Muskogee, OK 74401-5100 | 2016-02-16 |
| 1710384870 | Melisa Dean | Nurse Practitioner | 700 S Telephone Rd Ste 401, Moore, OK 73160-2548 | 2014-12-04 |
| 1356766315 | Brianna Weathers | Nurse Practitioner | 401 W Tamarack Rd, Altus, OK 73521-1529 | 2014-02-27 |
| 1932473568 | Julie Claire Styles | Nurse Practitioner | 1540 N Lewis Ave, Tulsa, OK 74110-2535 | 2012-02-29 |
| 1376825596 | Jaclyn Danielle Maphies | Nurse Practitioner | 800 N.e. 10th Street, Suite 2100, Oklahoma City, OK 73104-5418 | 2011-09-14 |
| 1104124502 | Toby Lea Miller | Nurse Practitioner | 1603 W 9th Ave, Stillwater, OK 74074-5202 | 2011-03-09 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.