MEDICARE: MELISSA WITHROW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1134527617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA WITHROW

Provider Business Mailing Address
First Line	:	4811 S JACKSON AVE
Second Line	:	APT 3
City	:	TULSA
State	:	OK
Zip	:	74107-8101
Country	:	US
Telephone Number	:	918-280-9104
Fax Number	:	918-609-2850

Provider Business Practice Location Address
First Line	:	514 W ATLANTA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-7004
Country	:	US
Telephone Number	:	918-280-9104
Fax Number	:	918-609-2850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	12/15/2014

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