Provider Demographics
NPI:1114782232
Name:MUSTACHIA, ELEANOR
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:MUSTACHIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAINE
Other - Middle Name:
Other - Last Name:MUSTACHIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:201 OAK TREE DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-3540
Mailing Address - Country:US
Mailing Address - Phone:405-845-5208
Mailing Address - Fax:
Practice Address - Street 1:1491 S SUNNYLANE RD
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3037
Practice Address - Country:US
Practice Address - Phone:405-437-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist