Provider Demographics
NPI:1316407315
Name:BLUNT, MARIAH DALEE I
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:DALEE
Last Name:BLUNT
Suffix:I
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 1:10604 E 96TH PL N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4343
Mailing Address - Country:US
Mailing Address - Phone:918-516-2050
Mailing Address - Fax:
Practice Address - Street 1:10604 E 96TH PL N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4343
Practice Address - Country:US
Practice Address - Phone:918-516-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK053730303Medicaid