Healthcare Provider Details

I. General information

NPI: 1821806324
Provider Name (Legal Business Name): CHANEL MIRIAM PHILIPOSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S FRETZ AVE
EDMOND OK
73003-5532
US

IV. Provider business mailing address

1600 KICKINGBIRD RD APT 312
EDMOND OK
73034-6246
US

V. Phone/Fax

Practice location:
  • Phone: 405-757-7980
  • Fax:
Mailing address:
  • Phone: 405-967-4035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: