Healthcare Provider Details

I. General information

NPI: 1639654429
Provider Name (Legal Business Name): SHEENA NIDIFFER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 S. MAIN ST
AFTON OK
74331
US

IV. Provider business mailing address

138 S MAIN
AFTON OK
74331-1822
US

V. Phone/Fax

Practice location:
  • Phone: 918-257-4244
  • Fax:
Mailing address:
  • Phone: 918-257-4244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: