Healthcare Provider Details

I. General information

NPI: 1952974370
Provider Name (Legal Business Name): MS. ASHLEY DOMINIQUE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. ASHLEY DOMINIQUE CLARK

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 S HARVARD AVE
TULSA OK
74114-3300
US

IV. Provider business mailing address

6608 S DATE AVE
BROKEN ARROW OK
74011-6619
US

V. Phone/Fax

Practice location:
  • Phone: 918-712-4301
  • Fax: 918-560-1399
Mailing address:
  • Phone: 210-919-2091
  • Fax:

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: