Basic Information
Provider Information | |||||||||
NPI: | 1376179119 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PATRICK | ||||||||
FirstName: | LATIFFANY | ||||||||
MiddleName: | DESHAWN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CMII | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2325 S HARVARD AVE | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741143300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187124301 | ||||||||
FaxNumber: | 9185601399 | ||||||||
Practice Location | |||||||||
Address1: | 2325 S HARVARD AVE | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741143300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187124301 | ||||||||
FaxNumber: | 9185601399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2020 | ||||||||
LastUpdateDate: | 02/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   |   | N |   |   |   |   | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 171M00000X |   | OK | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.