Healthcare Provider Details

I. General information

NPI: 1922916600
Provider Name (Legal Business Name): LISA MARIE WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 GORDON COOPER DR
SHAWNEE OK
74801-8603
US

IV. Provider business mailing address

1904 GORDON COOPER DR
SHAWNEE OK
74801-8603
US

V. Phone/Fax

Practice location:
  • Phone: 405-273-2157
  • Fax:
Mailing address:
  • Phone: 405-273-2157
  • Fax: 405-275-5167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number202532
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: