=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477870418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. AMY LADAWN HARBIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2010
-----------------------------------------------------
Last Update Date | 07/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14290 S 104TH ST W
-----------------------------------------------------
City | OKTAHA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74450-4126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-682-0839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 511
-----------------------------------------------------
City | CHECOTAH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74426-0511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-682-0839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------