Provider Demographics
NPI:1407448368
Name:ODOM-SULLIVAN, AMBER R
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:R
Last Name:ODOM-SULLIVAN
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 1:1420 E JENNINGS ST
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098-1020
Mailing Address - Country:US
Mailing Address - Phone:405-207-8510
Mailing Address - Fax:
Practice Address - Street 1:202 S WASHITA AVE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:OK
Practice Address - Zip Code:73098-7820
Practice Address - Country:US
Practice Address - Phone:405-665-4385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator