Provider Demographics
NPI:1497344873
Name:YOUNG, TIANDRA
Entity Type:Individual
Prefix:
First Name:TIANDRA
Middle Name:
Last Name:YOUNG
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:PO BOX 30301
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73140-3301
Mailing Address - Country:US
Mailing Address - Phone:405-537-4391
Mailing Address - Fax:
Practice Address - Street 1:777 N AIR DEPOT BLVD APT 5102
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-3771
Practice Address - Country:US
Practice Address - Phone:405-537-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator