Provider Demographics
NPI:1073765442
Name:RICE, GINA DIANE (RN)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:DIANE
Last Name:RICE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:GINA
Other - Middle Name:DIANE
Other - Last Name:LYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 164
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764-0164
Mailing Address - Country:US
Mailing Address - Phone:580-212-6366
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 374-5
Practice Address - Street 2:
Practice Address - City:VALLIANT
Practice Address - State:OK
Practice Address - Zip Code:74764-9807
Practice Address - Country:US
Practice Address - Phone:580-212-6366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OK83917163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)