Basic Information
| Provider Information | |||||||||
| NPI: | 1659627073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLTIZER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | R.N., BSN, MSM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 YELLOWSTONE LN | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730034675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058448894 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 430 W WILSHIRE BLVD | ||||||||
| Address2: | SUITES 9 & 10 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731167771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055218635 | ||||||||
| FaxNumber: | 4055218652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2012 | ||||||||
| LastUpdateDate: | 08/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | R 0026787 | OK | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent |
No ID Information.