Healthcare Provider Details

I. General information

NPI: 1770822017
Provider Name (Legal Business Name): SHAE LEGGETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2013
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 NW 48TH ST STE 102
OKLAHOMA CITY OK
73112-5911
US

IV. Provider business mailing address

3200 NW 48TH ST STE 102
OKLAHOMA CITY OK
73112-5911
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-6975
  • Fax: 405-605-8175
Mailing address:
  • Phone: 405-604-6975
  • Fax: 405-605-8175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: