Healthcare Provider Details

I. General information

NPI: 1871113878
Provider Name (Legal Business Name): KATHERINE LYNN HORN STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 S HARVARD AVE STE 135
TULSA OK
74135-2916
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 918-745-9662
  • Fax: 918-745-9663
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3076
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: