Basic Information
| Provider Information | |||||||||
| NPI: | 1417086380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINIELLY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ILLIG | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8100 S. WALKER AVENUE | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731399404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056324468 | ||||||||
| FaxNumber: | 4056314964 | ||||||||
| Practice Location | |||||||||
| Address1: | 8100 S. WALKER AVENUE | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731399404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056324468 | ||||||||
| FaxNumber: | 4056314964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R0059137 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | R0059137 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 100130740A | 01 | OK | OHCA | OTHER | 28812 | 01 | OK | ONBDD | OTHER | 100130740A | 01 | OK | SOONERCARE | OTHER | 12317438 | 01 | OK | CAQH | OTHER | 1417086380 | 01 | OK | NPI | OTHER | MM0630916 | 01 | OK | DEA | OTHER | 59137 | 01 | OK | LICENSE | OTHER |