Provider Demographics
NPI:1790673796
Name:WALTZ, BILLIE G
Entity type:Individual
Prefix:
First Name:BILLIE
Middle Name:G
Last Name:WALTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S 2 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-7803
Mailing Address - Country:US
Mailing Address - Phone:918-577-8215
Mailing Address - Fax:
Practice Address - Street 1:117 S 2 MILE RD
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434-7803
Practice Address - Country:US
Practice Address - Phone:918-577-8215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-26
Last Update Date:2025-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0087624163W00000X
KS13-63427-102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse