MEDICARE: AIYANNA TAHBONEMAH MCNEILL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-24-400266	OK

General Provider Information

NPI Number	:	1568272094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AIYANNA TAHBONEMAH MCNEILL

Provider Business Mailing Address
First Line	:	3110 W OKLAHOMA AVE
Second Line	:
City	:	ENID
State	:	OK
Zip	:	73703-5033
Country	:	US
Telephone Number	:	580-309-0353
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 W OKLAHOMA AVE
Second Line	:
City	:	ENID
State	:	OK
Zip	:	73703-5033
Country	:	US
Telephone Number	:	580-309-0353
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2025
Last Update Date	:	01/08/2025

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