Healthcare Provider Details

I. General information

NPI: 1235159666
Provider Name (Legal Business Name): EARLENA MCKEE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N GRAND AVE
TAHLEQUAH OK
74464-7017
US

IV. Provider business mailing address

1001 N GRAND AVE
TAHLEQUAH OK
74464-7017
US

V. Phone/Fax

Practice location:
  • Phone: 918-444-4051
  • Fax: 918-458-2310
Mailing address:
  • Phone: 918-444-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2197
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200028170A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: