Provider Demographics
NPI:1710396718
Name:PRUDHOMME, MARIA GABRIELLA (NP)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:GABRIELLA
Last Name:PRUDHOMME
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 NE 13TH ST STE 1C
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5040
Mailing Address - Country:US
Mailing Address - Phone:405-271-5992
Mailing Address - Fax:405-271-5992
Practice Address - Street 1:1000 NE 13TH ST # 1C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5040
Practice Address - Country:US
Practice Address - Phone:405-271-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213432363L00000X, 363LF0000X
TX1067064363L00000X, 363LF0000X
OK210652363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I507982Medicare PIN