Provider Demographics
NPI:1962401653
Name:SECRIST, MARY ANNE (MS, RN, CNS)
Entity type:Individual
Prefix:MS
First Name:MARY ANNE
Middle Name:
Last Name:SECRIST
Suffix:
Gender:F
Credentials:MS, RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-3834
Mailing Address - Country:US
Mailing Address - Phone:405-634-5529
Mailing Address - Fax:405-636-1673
Practice Address - Street 1:4720 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3834
Practice Address - Country:US
Practice Address - Phone:405-634-5529
Practice Address - Fax:405-636-1673
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0026857364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR0026857OtherRN LICENSE