Provider Demographics
NPI:1811080146
Name:MASSENGALE, TRACY L (ARNP)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:L
Last Name:MASSENGALE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13901 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1052
Mailing Address - Country:US
Mailing Address - Phone:405-606-2727
Mailing Address - Fax:405-606-7040
Practice Address - Street 1:13901 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1052
Practice Address - Country:US
Practice Address - Phone:405-606-2727
Practice Address - Fax:405-606-7040
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK44471363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100106970BMedicaid
OKS61420Medicare UPIN
OK100106970BMedicaid