Provider Demographics
NPI:1538460787
Name:LEE-OSINBOWALE, LATASHUA DIANE
Entity Type:Individual
Prefix:
First Name:LATASHUA
Middle Name:DIANE
Last Name:LEE-OSINBOWALE
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 1:801 NW 137TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1952
Mailing Address - Country:US
Mailing Address - Phone:918-850-0886
Mailing Address - Fax:
Practice Address - Street 1:801 NW 137TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1952
Practice Address - Country:US
Practice Address - Phone:918-850-0886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKH080268165171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator