Basic Information
| Provider Information | |||||||||
| NPI: | 1770571598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOMENS HEALTH & WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 E OKLAHOMA AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737015951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802423870 | ||||||||
| FaxNumber: | 5802424046 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 E OKLAHOMA AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737015951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802423870 | ||||||||
| FaxNumber: | 5802424046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 02/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | GIBSON-BURRIS | ||||||||
| AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGEMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5802493706 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. MARY PHYSICIAN ASSOCIATES, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 11867 | OK | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 363LX0001X | R0048498 | OK | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 207V00000X | 8721 | OK | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.