Basic Information
| Provider Information | |||||||||
| NPI: | 1760003305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REEDER | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9900 W HIGHWAY 66 APT 1407 | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730990018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052297617 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5208 W RENO AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731276344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059484900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2020 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.