Healthcare Provider Details

I. General information

NPI: 1992135511
Provider Name (Legal Business Name): AUDREY HATHORN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2013
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 N.W. 39TH ST 103
OKLAHOMA CITY OK
73112
US

IV. Provider business mailing address

2401 N.W. 39TH ST 103
OKLAHOMA CITY OK
73112
US

V. Phone/Fax

Practice location:
  • Phone: 405-601-9668
  • Fax: 405-606-7893
Mailing address:
  • Phone: 405-601-9668
  • Fax: 405-606-7893

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: