Healthcare Provider Details

I. General information

NPI: 1043541568
Provider Name (Legal Business Name): AMBER ZUMWALT MED CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5704 NW 163RD TER
EDMOND OK
73013-9434
US

IV. Provider business mailing address

5704 NW 163RD TER
EDMOND OK
73013-9434
US

V. Phone/Fax

Practice location:
  • Phone: 405-659-5857
  • Fax:
Mailing address:
  • Phone: 405-659-5857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2644
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number09144518 ASHA
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: