Provider Demographics
NPI:1629365713
Name:FALLWELL, EMILIE CHARLENE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:EMILIE
Middle Name:CHARLENE
Last Name:FALLWELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 W GORE BLVD STE A2
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5977
Mailing Address - Country:US
Mailing Address - Phone:580-699-8383
Mailing Address - Fax:580-699-8381
Practice Address - Street 1:4411 W GORE BLVD STE A2
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5977
Practice Address - Country:US
Practice Address - Phone:580-699-8383
Practice Address - Fax:580-699-8381
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK83413363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily