Healthcare Provider Details

I. General information

NPI: 1013606730
Provider Name (Legal Business Name): ANGELA JEAN OWINGS MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N HIGH ST
ANTLERS OK
74523-2238
US

IV. Provider business mailing address

301 N HIGH ST
ANTLERS OK
74523-2238
US

V. Phone/Fax

Practice location:
  • Phone: 580-271-7055
  • Fax:
Mailing address:
  • Phone: 580-271-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: