Healthcare Provider Details

I. General information

NPI: 1023302650
Provider Name (Legal Business Name): MRS. AMANDA KAY BLUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 05/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 WEST MAIN
TISHOMINGO OK
73460
US

IV. Provider business mailing address

PO BOX 194
MILBURN OK
73450-0194
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-8719
  • Fax:
Mailing address:
  • Phone: 580-371-8719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: