Provider Demographics
NPI:1083643183
Name:MCILWEE, LINDA J (CRNA)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:J
Last Name:MCILWEE
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 1:626 DEER RUN
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-3426
Mailing Address - Country:US
Mailing Address - Phone:580-242-3003
Mailing Address - Fax:580-237-6174
Practice Address - Street 1:600 S MONROE ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-7211
Practice Address - Country:US
Practice Address - Phone:580-233-2300
Practice Address - Fax:580-237-6174
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0024786207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100788620AMedicaid
OK100788620AMedicaid