Provider Demographics
NPI:1003245481
Name:WILMARTH, TRACI RENEE (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:RENEE
Last Name:WILMARTH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9713 LAKECREST DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6777
Mailing Address - Country:US
Mailing Address - Phone:405-213-5351
Mailing Address - Fax:
Practice Address - Street 1:9713 LAKECREST DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6777
Practice Address - Country:US
Practice Address - Phone:405-213-5351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100545367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1003245481Medicaid