Healthcare Provider Details

I. General information

NPI: 1699640235
Provider Name (Legal Business Name): MANDY BOTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 E 2ND ST
HEAVENER OK
74937-3419
US

IV. Provider business mailing address

PO BOX 579
MCALESTER OK
74502-0579
US

V. Phone/Fax

Practice location:
  • Phone: 918-653-7718
  • Fax: 918-653-7279
Mailing address:
  • Phone: 918-426-7800
  • Fax: 918-426-5837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberR0123711
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: