Healthcare Provider Details

I. General information

NPI: 1609207166
Provider Name (Legal Business Name): KHRYSTAL KAY HUMBLE BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 E FRESNO AVE
PONCA CITY OK
74601-2817
US

IV. Provider business mailing address

508 E FRESNO AVE
PONCA CITY OK
74601-2817
US

V. Phone/Fax

Practice location:
  • Phone: 580-767-9035
  • Fax: 580-762-1157
Mailing address:
  • Phone: 580-767-9035
  • Fax: 580-762-1157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number157768
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: