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General NPI Number Information
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NPI Number | 1912436957
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Entity Type | Individual
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Provider Name | CHRISTINA LICONA LMT
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Gender | Female
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Dates
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Enumeration Date | 06/04/2017
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Last Update Date | 06/04/2017
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Provider Practice Location Address
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Address Line | 12806 E 86TH PL N
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City | OWASSO
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State | OK
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Zip | 74055-2687
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Country | US
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Telephone | 918-277-1242
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Fax |
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Provider Business Mailing Address
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Address Line | 7905 N 122ND EAST AVE
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City | OWASSO
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State | OK
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Zip | 74055-3529
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Country | US
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Telephone | 918-277-1242
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 156805
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License Number State | OK
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