1174033039 NPI number — DIANA LYNN PARENT

Table of content: DIANA LYNN PARENT (NPI 1174033039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174033039 NPI number — DIANA LYNN PARENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARENT
Provider First Name:
DIANA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PARENT
Provider Other First Name:
DIANA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DIANA LYNN MARTIN
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1174033039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5310 E 31ST ST STE 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74135-5014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-599-7404
Provider Business Mailing Address Fax Number:
918-777-9016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 S HARVARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74114-3300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-599-7404
Provider Business Practice Location Address Fax Number:
918-382-1881
Provider Enumeration Date:
10/05/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 175T00000X , with the licence number:  U080054193 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1174033039 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".