Provider Demographics
NPI:1174842645
Name:FARRIS, SUSANNAH RENEE
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:RENEE
Last Name:FARRIS
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:RR 1 BOX 241AA
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-9059
Mailing Address - Country:US
Mailing Address - Phone:580-465-8408
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 241AA
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-9059
Practice Address - Country:US
Practice Address - Phone:580-465-8408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator