Basic Information
| Provider Information | |||||||||
| NPI: | 1609360858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANN | ||||||||
| FirstName: | TRACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 N FAIRLAND ST | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743614203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188251405 | ||||||||
| FaxNumber: | 9188251406 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 N FAIRLAND ST | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188251405 | ||||||||
| FaxNumber: | 9188251406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2018 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.