Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1174186191 |
---|---|
Provider Name | Ms. Charlesetta Maria Thompson |
First Address | Oklahoma City, OK 73102-2619 |
Second Address | Oklahoma City, OK 73102-2619 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2019 |
Last Update Date | 16/04/2019 |