Provider Demographics
NPI:1396027470
Name:MOLDRUP, FIONNA JAYNE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:FIONNA
Middle Name:JAYNE
Last Name:MOLDRUP
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-0272
Mailing Address - Country:US
Mailing Address - Phone:918-696-3101
Mailing Address - Fax:918-696-7031
Practice Address - Street 1:1401 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-3275
Practice Address - Country:US
Practice Address - Phone:918-696-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist