Basic Information
| Provider Information | |||||||||
| NPI: | 1720189350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOMACK | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | CERISE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 W.MEMORIAL RD | ||||||||
| Address2: | 901 | ||||||||
| City: | OKLAHOMA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057494247 | ||||||||
| FaxNumber: | 4057494249 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 W MEMORIAL RD | ||||||||
| Address2: | 901 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057494247 | ||||||||
| FaxNumber: | 4057494249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 08/13/2014 | ||||||||
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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 | 363L00000X | R0062718 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 100214830A | 05 | OK | MEDICAID |