Provider Demographics
NPI:1376838086
Name:IDLEMAN, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:IDLEMAN
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 1:6008 RECK RD.
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:OK
Mailing Address - Zip Code:73463
Mailing Address - Country:US
Mailing Address - Phone:580-668-1109
Mailing Address - Fax:
Practice Address - Street 1:109 SOUTH 1ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446
Practice Address - Country:US
Practice Address - Phone:580-795-3731
Practice Address - Fax:580-795-3170
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid