Healthcare Provider Details

I. General information

NPI: 1811691363
Provider Name (Legal Business Name): TIMANISHA HOLBERT I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1137 E KENOSHA ST
BROKEN ARROW OK
74012-2006
US

IV. Provider business mailing address

3302 GASTON AVE
DALLAS TX
75246-2013
US

V. Phone/Fax

Practice location:
  • Phone: 918-259-0239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8233
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: