Provider Demographics
NPI:1770571598
Name:WOMENS HEALTH & WELLNESS
Entity type:Organization
Organization Name:WOMENS HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGEMENT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON-BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:580-249-3706
Mailing Address - Street 1:615 E OKLAHOMA AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5951
Mailing Address - Country:US
Mailing Address - Phone:580-242-3870
Mailing Address - Fax:580-242-4046
Practice Address - Street 1:615 E OKLAHOMA AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5951
Practice Address - Country:US
Practice Address - Phone:580-242-3870
Practice Address - Fax:580-242-4046
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY PHYSICIAN ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-06
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11867207VG0400X
OKR0048498363LX0001X
OK8721207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty