Provider Demographics
NPI:1508393042
Name:GILLEY, TRACI DAWN
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:DAWN
Last Name:GILLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:DAWN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:407 N TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-4630
Mailing Address - Country:US
Mailing Address - Phone:903-818-3663
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5305
Practice Address - Country:US
Practice Address - Phone:405-307-4839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0119242163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult