Healthcare Provider Details

I. General information

NPI: 1861737975
Provider Name (Legal Business Name): MRS. LAURA DIEDRA NUBINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. LAURA DIEDRA HOWARD

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 N KELLEY AVE SUITE 100
OKLAHOMA CITY OK
73111-4520
US

IV. Provider business mailing address

11219 N PENNSYLVANIA AVE APT 706
OKLAHOMA CITY OK
73120-7734
US

V. Phone/Fax

Practice location:
  • Phone: 405-524-5525
  • Fax: 405-524-5528
Mailing address:
  • Phone: 405-760-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: