Provider Demographics
NPI:1568103588
Name:DURRAH, MINYON ELIZABETH ETTA
Entity Type:Individual
Prefix:MISS
First Name:MINYON
Middle Name:ELIZABETH ETTA
Last Name:DURRAH
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 1:808 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4427
Mailing Address - Country:US
Mailing Address - Phone:234-600-6469
Mailing Address - Fax:
Practice Address - Street 1:808 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-4427
Practice Address - Country:US
Practice Address - Phone:234-600-6469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty