Provider Demographics
NPI:1326484015
Name:HEADLEY, SHANNON REBEKAH (DO, MA)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:REBEKAH
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:DO, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 S HOUSTON AVE #A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9023
Mailing Address - Country:US
Mailing Address - Phone:918-382-3178
Mailing Address - Fax:918-382-6789
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AZR3534208600000X
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No208600000XAllopathic & Osteopathic PhysiciansSurgery