Healthcare Provider Details

I. General information

NPI: 1568866374
Provider Name (Legal Business Name): MRS. DIAN MOHAMMED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 NW 39TH EXPY STE 103
OKLAHOMA CITY OK
73112-8739
US

IV. Provider business mailing address

11205 N PENN AVE APT 224
OKLAHOMA CITY OK
73120-7723
US

V. Phone/Fax

Practice location:
  • Phone: 405-601-9668
  • Fax:
Mailing address:
  • Phone: 405-413-3602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number37V576030806
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: