Provider Demographics
NPI:1508497173
Name:BAKEN, CHASTITY FAWN
Entity Type:Individual
Prefix:
First Name:CHASTITY
Middle Name:FAWN
Last Name:BAKEN
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 970
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-0970
Mailing Address - Country:US
Mailing Address - Phone:580-371-3019
Mailing Address - Fax:580-371-0138
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:580-371-3019
Practice Address - Fax:580-371-0138
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator