Healthcare Provider Details

I. General information

NPI: 1275882862
Provider Name (Legal Business Name): MS. KARISE TREVON DYKES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. KARISE TREVON WILLIS

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NW 10TH ST
OKLAHOMA CITY OK
73106-7220
US

IV. Provider business mailing address

2217 SW 94TH TER
OKLAHOMA CITY OK
73159-6851
US

V. Phone/Fax

Practice location:
  • Phone: 405-528-4673
  • Fax:
Mailing address:
  • Phone: 714-574-5553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: