MEDICARE: MS. LATANYA D NICHOLAS

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1265778344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LATANYA D NICHOLAS

Provider Business Mailing Address
First Line	:	2520 SW 45TH ST
Second Line	:	OKLAHOMA
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73119-4609
Country	:	US
Telephone Number	:	405-474-1638
Fax Number	:

Provider Business Practice Location Address
First Line	:	2520 SW 45TH ST
Second Line	:	OKLAHOMA
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73119-4609
Country	:	US
Telephone Number	:	405-474-1638
Fax Number	:

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

Provider Enumeration Date	:	12/18/2012
Last Update Date	:	12/18/2012

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