Provider Demographics
NPI:1154179307
Name:MULLENDORE, TRACIE MARIE
Entity type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:MARIE
Last Name:MULLENDORE
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 1:26239 N COUNTY ROAD 3210
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-9205
Mailing Address - Country:US
Mailing Address - Phone:405-207-4592
Mailing Address - Fax:
Practice Address - Street 1:26239 N COUNTY ROAD 3210
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:OK
Practice Address - Zip Code:73098-9205
Practice Address - Country:US
Practice Address - Phone:405-207-4592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator