Healthcare Provider Details

I. General information

NPI: 1457899288
Provider Name (Legal Business Name): AMY NJENGA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N BROADWAY ST STE B
MOORE OK
73160-5108
US

IV. Provider business mailing address

103 N BROADWAY ST STE B
MOORE OK
73160-5108
US

V. Phone/Fax

Practice location:
  • Phone: 405-514-7910
  • Fax:
Mailing address:
  • Phone: 405-514-7910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0043678
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number172258-0
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: