Healthcare Provider Details

I. General information

NPI: 1508497173
Provider Name (Legal Business Name): CHASTITY FAWN BAKEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2020
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W MAIN ST
TISHOMINGO OK
73460-1723
US

IV. Provider business mailing address

PO BOX 970
TISHOMINGO OK
73460-0970
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-3019
  • Fax: 580-371-0138
Mailing address:
  • Phone: 580-371-3019
  • Fax: 580-371-0138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: