Basic Information
| Provider Information | |||||||||
| NPI: | 1720313901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIENNA | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DI ENNA | ||||||||
| OtherFirstName: | CHRISTINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3433 NW 56TH ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059473341 | ||||||||
| FaxNumber: | 4059453197 | ||||||||
| Practice Location | |||||||||
| Address1: | 3433 NW 56TH ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059473341 | ||||||||
| FaxNumber: | 4059453126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2009 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5848 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 4352 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208D00000X | UO2253 | FL | N | Allopathic & Osteopathic Physicians | General Practice | 207RC0000X | 5848 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 200617410A | 05 | OK | MEDICAID |