Healthcare Provider Details

I. General information

NPI: 1972112290
Provider Name (Legal Business Name): ASHTON NICOLE AMOS ST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2224 W 111TH ST S
JENKS OK
74037-1713
US

IV. Provider business mailing address

2224 W 111TH ST S
JENKS OK
74037-1713
US

V. Phone/Fax

Practice location:
  • Phone: 918-645-7766
  • Fax:
Mailing address:
  • Phone: 918-645-7766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: