Healthcare Provider Details

I. General information

NPI: 1588286728
Provider Name (Legal Business Name): NAKIA SHANAE HISHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W I 240 SERVICE RD
OKLAHOMA CITY OK
73139-7701
US

IV. Provider business mailing address

10417 BUCCANEER DR
OKLAHOMA CITY OK
73159-6039
US

V. Phone/Fax

Practice location:
  • Phone: 405-635-3864
  • Fax: 405-604-9689
Mailing address:
  • Phone: 405-886-5092
  • Fax: 405-604-9689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: