Phyllis A Wallace, APRN

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

35497 Issued in OK

Practice address

527 W 3Rd St
Konawa, OK 74849-1415

Phone

(580) 925-3286

Fax

(580) 925-9149

NPI assigned

Jun 16, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in OK

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

University of Nebraska College of Medicine, 2002

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Central Oklahoma Family Medical Center IncGroup PAC ID 9931189685, 57 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Mercy Hospital Ada Hospital, Ada, OK, CCN 370020
• SSM Health St Anthony Hospital - Shawnee Hospital, Shawnee, OK, CCN 370149

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: phyllis.wallace@cof.eclinicaldirectplus.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Central Oklahoma Family Medical Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Konawa, OK
  • NPI 1831291293
  Medicare reassignment Care Compare group NPD
• Central Oklahoma Family Medical Center Inc

  • Federally Qualified Health Center (FQHC)
  • Ada, OK
  • NPI 1770399008
  NPD
• Central Oklahoma Family Medical Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Ada, OK
  • NPI 1386380178
  NPD
• Ada Gynecology & Obstetrics

  • Preferred Provider Organization
  • Ada, OK
  • NPI 1881717544
  NPD (past)
• Box Butte General Hospital

  • Rural Health Clinic/Center
  • Hemingford, NE
  • NPI 1609944388
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Mercy Hospital Ada, Inc

  • Ambulance
  • Ada, OK
  • NPI 1831533728

  Hospital

  Care Compare affiliation
• Mercy Hospital Ada, Inc

  • General Acute Care Hospital
  • Ada, OK
  • NPI 1952643306
  Care Compare affiliation
• St Anthony Shawnee Hospital Inc

  • General Acute Care Hospital
  • Shawnee, OK
  • NPI 1134123193
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150416000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1637539200000",
    "number": "1366486417",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "527 W 3RD ST",
            "city": "KONAWA",
            "state": "OK",
            "postal_code": "748491415",
            "telephone_number": "580-925-3286",
            "fax_number": "580-925-9149"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "527 W 3RD ST",
            "city": "KONAWA",
            "state": "OK",
            "postal_code": "748491415",
            "telephone_number": "580-925-3286",
            "fax_number": "580-925-9149"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "PHYLLIS",
        "middle_name": "A",
        "name_prefix": "Mrs.",
        "credential": "APRN",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-06-16",
        "last_updated": "2021-11-22",
        "certification_date": "2021-11-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LW0102X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Women's Health",
            "state": "OK",
            "license": "R0035497",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "OK",
            "license": "35497",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100155800A",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SOONERCARE PROVIDER",
            "identifier": "100155800B",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Paul Tucker, LCSW
• Marvin Charles Turner Jr.
• Toni Faye Vandegrift, DPH
• Destinie Rose Vincent
• Tina Marie Wainwright, P.A-C
• Winifred Watson, LCSW
• Dustin Charles Watterson, D.D.S.
• Mary Webb
• Todd Webb
• Erin Wetherill-Ochoa, CM II, CPRP

• Family Nurse Practitioner in Konawa, OK
• Providers in Konawa, OK by specialty
• Family Nurse Practitioner in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.