Basic Information
| Provider Information | |||||||||
| NPI: | 1174033039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PARENT | ||||||||
| OtherFirstName: | DIANA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2109 S HIGHWAY 69 | ||||||||
| Address2: | |||||||||
| City: | WAGONER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744679310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187083006 | ||||||||
| FaxNumber: | 9187779016 | ||||||||
| Practice Location | |||||||||
| Address1: | 2325 S HARVARD AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741143300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185997404 | ||||||||
| FaxNumber: | 9183821881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2017 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 175T00000X | U080054193 | OK | Y |
ID Information
| ID | Type | State | Issuer | Description | 1174033039 | 05 | OK | MEDICAID |