Basic Information
| Provider Information | |||||||||
| NPI: | 1457078628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNUTT | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 13404 N MERIDIAN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057522264 | ||||||||
| FaxNumber: | 4057524638 | ||||||||
| Practice Location | |||||||||
| Address1: | 13404 N MERIDIAN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057522264 | ||||||||
| FaxNumber: | 4057524638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2022 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 22234244 | OK | Y |
No ID Information.