Healthcare Provider Details

I. General information

NPI: 1194779744
Provider Name (Legal Business Name): LAURIE ELIZABETH MICKLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURIE MICKLE-BELL MD

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 05/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10512 N 110TH EAST AVE SUITE 300
OWASSO OK
74055-6636
US

IV. Provider business mailing address

10512 N 110TH EAST AVE SUITE 300
OWASSO OK
74055-6636
US

V. Phone/Fax

Practice location:
  • Phone: 918-376-8901
  • Fax: 918-376-8939
Mailing address:
  • Phone: 918-376-8901
  • Fax: 918-376-8939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17332
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: