Provider Demographics
NPI:1114791241
Name:KRUTA, TIARA DONN MCKENSIE
Entity Type:Individual
Prefix:
First Name:TIARA DONN
Middle Name:MCKENSIE
Last Name:KRUTA
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 1:13501 SE 29TH ST TRLR 121
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-6652
Mailing Address - Country:US
Mailing Address - Phone:405-305-7210
Mailing Address - Fax:
Practice Address - Street 1:13501 SE 29TH ST TRLR 121
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-6652
Practice Address - Country:US
Practice Address - Phone:405-305-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator