Healthcare Provider Details

I. General information

NPI: 1609990639
Provider Name (Legal Business Name): KRYSTAL NICOLE MARTIN BA BHRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 ALAMEDA ST
NORMAN OK
73071-5229
US

IV. Provider business mailing address

3156 W ROCK CREEK RD APT 1611
NORMAN OK
73072-2480
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-5100
  • Fax: 405-573-3958
Mailing address:
  • Phone: 580-467-2203
  • Fax: 405-573-3958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: