Healthcare Provider Details

I. General information

NPI: 1124948294
Provider Name (Legal Business Name): DEASHIA SHANNICE COGDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5509 MAIN ST STE 102
DEL CITY OK
73115-5511
US

IV. Provider business mailing address

11810 NE 46TH ST
SPENCER OK
73084-7311
US

V. Phone/Fax

Practice location:
  • Phone: 405-627-9308
  • Fax:
Mailing address:
  • Phone: 405-902-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: