Healthcare Provider Details

I. General information

NPI: 1912447558
Provider Name (Legal Business Name): DANA K LARUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14685 W VAN BUREN ST
CRESCENT OK
73028-8789
US

IV. Provider business mailing address

14685 W VAN BUREN ST
CRESCENT OK
73028-8789
US

V. Phone/Fax

Practice location:
  • Phone: 405-249-2990
  • Fax:
Mailing address:
  • Phone: 405-249-2990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: