Provider Demographics
NPI:1437797974
Name:KLEINERT, ELLEN CIERRA
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:CIERRA
Last Name:KLEINERT
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 1:108 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-1723
Mailing Address - Country:US
Mailing Address - Phone:903-267-4283
Mailing Address - Fax:
Practice Address - Street 1:108 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-1723
Practice Address - Country:US
Practice Address - Phone:903-267-4283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1995Medicaid
OK730618672Medicaid