Healthcare Provider Details

I. General information

NPI: 1194559757
Provider Name (Legal Business Name): ANTUANETTE MARJORIE MAYSUNDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 W 31ST ST
TULSA OK
74107-4219
US

IV. Provider business mailing address

13779 S POPLAR ST
GLENPOOL OK
74033-3255
US

V. Phone/Fax

Practice location:
  • Phone: 918-884-1070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
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: