Healthcare Provider Details

I. General information

NPI: 1225679178
Provider Name (Legal Business Name): PAMELA HATHORN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 HOLIDAY DR
ARDMORE OK
73401-1216
US

IV. Provider business mailing address

320 SINCLAIR ST
HEALDTON OK
73438-2632
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-5003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: