Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003049370 |
---|---|
Provider Name | Felicia Fagan |
First Address | Tulsa, OK 74119-5234 |
Second Address | Tulsa, OK 74119-5234 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2009 |
Last Update Date | 03/09/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5FKF76 | ICIS (01) | OK |