Provider Demographics
NPI:1154679553
Name:CUNNINGHAM, MARSHA LYNNETTE
Entity Type:Individual
Prefix:MRS
First Name:MARSHA
Middle Name:LYNNETTE
Last Name:CUNNINGHAM
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 1:1924 CECIL ST
Mailing Address - Street 2:
Mailing Address - City:WAYNOKA
Mailing Address - State:OK
Mailing Address - Zip Code:73860-1283
Mailing Address - Country:US
Mailing Address - Phone:580-737-0235
Mailing Address - Fax:
Practice Address - Street 1:1095 NICKERSON ST
Practice Address - Street 2:
Practice Address - City:WAYNOKA
Practice Address - State:OK
Practice Address - Zip Code:73860-1252
Practice Address - Country:US
Practice Address - Phone:580-824-0674
Practice Address - Fax:580-824-0676
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24084171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator