Provider Demographics
NPI:1154486629
Name:BEAGLES, GRETCHEN MICHELLE (CCP LP)
Entity Type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:MICHELLE
Last Name:BEAGLES
Suffix:
Gender:F
Credentials:CCP LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12815
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73157-2815
Mailing Address - Country:US
Mailing Address - Phone:405-604-5613
Mailing Address - Fax:405-601-3750
Practice Address - Street 1:3601 N MAY AVE
Practice Address - Street 2:SUITE C
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6641
Practice Address - Country:US
Practice Address - Phone:405-604-5613
Practice Address - Fax:405-601-3750
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLP63247200000X, 242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
5993501OtherAETNA
731522080002OtherBCBS