Healthcare Provider Details

I. General information

NPI: 1932772068
Provider Name (Legal Business Name): AMANDA HUCKABY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MEDICAL PKWY
CLAREMORE OK
74017-1088
US

IV. Provider business mailing address

3100 MEDICAL PKWY
CLAREMORE OK
74017-1088
US

V. Phone/Fax

Practice location:
  • Phone: 918-342-0770
  • Fax: 918-342-0097
Mailing address:
  • Phone: 918-342-0770
  • Fax: 918-342-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0129884
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: