Healthcare Provider Details

I. General information

NPI: 1992975387
Provider Name (Legal Business Name): REIDA LORI WASSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 S 17TH ST
CHICKASHA OK
73018-6408
US

IV. Provider business mailing address

2702 S 17TH ST
CHICKASHA OK
73018-6408
US

V. Phone/Fax

Practice location:
  • Phone: 405-320-5040
  • Fax:
Mailing address:
  • Phone: 405-320-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number809
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: