Provider Demographics
NPI:1417086380
Name:MINIELLY, MARY ILLIG (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ILLIG
Last Name:MINIELLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 S. WALKER AVENUE
Mailing Address - Street 2:BUILDING A
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9404
Mailing Address - Country:US
Mailing Address - Phone:405-632-4468
Mailing Address - Fax:405-631-4964
Practice Address - Street 1:8100 S. WALKER AVENUE
Practice Address - Street 2:BUILDING A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9404
Practice Address - Country:US
Practice Address - Phone:405-632-4468
Practice Address - Fax:405-631-4964
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0059137363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100130740AOtherOHCA
OK28812OtherONBDD
OK100130740AOtherSOONERCARE
OK12317438OtherCAQH
OK1417086380OtherNPI
OK59137OtherLICENSE
OK59137OtherLICENSE
OK59137OtherLICENSE