Healthcare Provider Details

I. General information

NPI: 1801521877
Provider Name (Legal Business Name): KATIE YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 11/26/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 HAR-BER DR
GROVE OK
74344
US

IV. Provider business mailing address

405 E EXCELSIOR AVE
VINITA OK
74301-4226
US

V. Phone/Fax

Practice location:
  • Phone: 918-256-6476
  • Fax:
Mailing address:
  • Phone: 918-256-6476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: