Provider Demographics
NPI:1093236929
Name:HUDSON, MYSTERY ALISHA
Entity Type:Individual
Prefix:
First Name:MYSTERY
Middle Name:ALISHA
Last Name:HUDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W CHINCAPIN
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74965-0410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W CHINCAPIN
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:OK
Practice Address - Zip Code:74965-0410
Practice Address - Country:US
Practice Address - Phone:918-723-3181
Practice Address - Fax:918-723-4581
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X
OK251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1164404190Medicaid