Healthcare Provider Details

I. General information

NPI: 1164044848
Provider Name (Legal Business Name): SHELBY LYNN EASON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S MURRAY ST
TISHOMINGO OK
73460-2224
US

IV. Provider business mailing address

8201 S ROCK CREEK LOOP
TISHOMINGO OK
73460-4419
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-0321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: