Provider Demographics
NPI:1215185491
Name:PROVIDENCE FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:PROVIDENCE FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP-C
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIANA
Authorized Official - Middle Name:ENANGA
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:405-816-0053
Mailing Address - Street 1:1016 SW 44TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-3617
Mailing Address - Country:US
Mailing Address - Phone:405-702-9050
Mailing Address - Fax:
Practice Address - Street 1:1016 SW 44TH ST STE 400
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3617
Practice Address - Country:US
Practice Address - Phone:405-702-9050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-31
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0058523261QP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200087300AMedicaid