1871752097 NPI number — MISS MARY KATHERINE MOULTON M.S.

Table of content: MISS MARY KATHERINE MOULTON M.S. (NPI 1871752097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871752097 NPI number — MISS MARY KATHERINE MOULTON M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOULTON
Provider First Name:
MARY
Provider Middle Name:
KATHERINE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOULTON
Provider Other First Name:
K.K.
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1871752097
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5327 E 3RD ST
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:
74112-1411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-850-6728
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
231 E GRAHAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRYOR
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74361-2436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-825-1405
Provider Business Practice Location Address Fax Number:
918-825-1406
Provider Enumeration Date:
06/03/2008

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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