Provider Demographics
NPI:1659078129
Name:DIFUNTORUM, MARY GRACE (APRN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY GRACE
Middle Name:
Last Name:DIFUNTORUM
Suffix:
Gender:F
Credentials:APRN, FNP
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 45561
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73145-0561
Mailing Address - Country:US
Mailing Address - Phone:405-605-3654
Mailing Address - Fax:
Practice Address - Street 1:901 N PORTER AVE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6404
Practice Address - Country:US
Practice Address - Phone:405-307-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK210920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily