Healthcare Provider Details

I. General information

NPI: 1043055544
Provider Name (Legal Business Name): MARINA RACHELLE ANDALUZ-BATES LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6925 S CANTON AVE
TULSA OK
74136-3418
US

IV. Provider business mailing address

6925 S CANTON AVE
TULSA OK
74136-3418
US

V. Phone/Fax

Practice location:
  • Phone: 918-932-8164
  • Fax:
Mailing address:
  • Phone: 918-932-8164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMIDW0051
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: