MEDICARE: KIMYATTA HISHAW

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	101Y00000X	Counselor	101YA0400X	OK

General Provider Information

NPI Number	:	1497185607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMYATTA HISHAW

Provider Business Mailing Address
First Line	:	10505 N MILITARY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-5226
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10505 N MILITARY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-5226
Country	:	US
Telephone Number	:	405-473-3849
Fax Number	:

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

Provider Enumeration Date	:	11/25/2013
Last Update Date	:	11/25/2013

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