Provider Demographics
NPI:1578760203
Name:EAGLIN, ALICE FAYE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:FAYE
Last Name:EAGLIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31850 SO 4320 RD
Mailing Address - Street 2:
Mailing Address - City:BIG CABIN
Mailing Address - State:OK
Mailing Address - Zip Code:74332
Mailing Address - Country:US
Mailing Address - Phone:918-693-5209
Mailing Address - Fax:
Practice Address - Street 1:31850 SO 4320 RD
Practice Address - Street 2:
Practice Address - City:BIG CABIN
Practice Address - State:OK
Practice Address - Zip Code:74332
Practice Address - Country:US
Practice Address - Phone:918-693-5209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK320600000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered347C00000XTransportation ServicesPrivate Vehicle