Healthcare Provider Details

I. General information

NPI: 1649501479
Provider Name (Legal Business Name): KENICA AMANDA THOMASON D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2010
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 COMMONS CIR A
YUKON OK
73099
US

IV. Provider business mailing address

1809 COMMONS CIR A
YUKON OK
73099
US

V. Phone/Fax

Practice location:
  • Phone: 405-577-6268
  • Fax: 405-577-6371
Mailing address:
  • Phone: 405-577-6268
  • Fax: 405-577-6371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3931
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: