Provider Demographics
NPI:1518624626
Name:QUIRK, MARY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:QUIRK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:KEOTA
Mailing Address - State:OK
Mailing Address - Zip Code:74941-0405
Mailing Address - Country:US
Mailing Address - Phone:918-471-3223
Mailing Address - Fax:
Practice Address - Street 1:20227 N COUNTY ROAD 4545 UNIT A
Practice Address - Street 2:
Practice Address - City:KEOTA
Practice Address - State:OK
Practice Address - Zip Code:74941-6800
Practice Address - Country:US
Practice Address - Phone:918-471-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator