Provider Demographics
NPI:1598494684
Name:MATTHEWS, LADAYSHA
Entity Type:Individual
Prefix:
First Name:LADAYSHA
Middle Name:
Last Name:MATTHEWS
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 1:501 W 15TH ST APT 132
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3649
Mailing Address - Country:US
Mailing Address - Phone:405-985-0093
Mailing Address - Fax:
Practice Address - Street 1:525 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-9046
Practice Address - Country:US
Practice Address - Phone:405-726-8966
Practice Address - Fax:405-726-8967
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200475600AMedicaid