Provider Demographics
NPI:1275164113
Name:JEFFERSON-SPEED, ELLA
Entity Type:Individual
Prefix:MRS
First Name:ELLA
Middle Name:
Last Name:JEFFERSON-SPEED
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 1:3612 OAK GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-3728
Mailing Address - Country:US
Mailing Address - Phone:405-863-5578
Mailing Address - Fax:
Practice Address - Street 1:3612 OAK GROVE DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-3728
Practice Address - Country:US
Practice Address - Phone:405-863-5578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist