Provider Demographics
NPI:1871295774
Name:MODIFY, PLLC
Entity type:Organization
Organization Name:MODIFY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN-CNS,BC-ADM
Authorized Official - Phone:918-857-2135
Mailing Address - Street 1:8263 S HARVARD AVE # 715
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-1614
Mailing Address - Country:US
Mailing Address - Phone:918-857-2135
Mailing Address - Fax:
Practice Address - Street 1:7804 E 108TH ST STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7423
Practice Address - Country:US
Practice Address - Phone:918-857-2135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-22
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty