Provider Demographics
NPI:1558700773
Name:GRIFFIN, LUCKY SUE
Entity Type:Individual
Prefix:
First Name:LUCKY
Middle Name:SUE
Last Name:GRIFFIN
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 1:630 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3016
Mailing Address - Country:US
Mailing Address - Phone:580-399-8047
Mailing Address - Fax:
Practice Address - Street 1:620 E COURT ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-3016
Practice Address - Country:US
Practice Address - Phone:580-399-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172V00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker