Provider Demographics
NPI:1619106853
Name:GRAYSON, WILLETTA RUTH (SERVICE PROVIDER)
Entity Type:Individual
Prefix:
First Name:WILLETTA
Middle Name:RUTH
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:SERVICE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 686
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-9779
Mailing Address - Country:US
Mailing Address - Phone:580-286-5102
Mailing Address - Fax:580-286-5929
Practice Address - Street 1:RR 1 BOX 686
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-9779
Practice Address - Country:US
Practice Address - Phone:580-286-5102
Practice Address - Fax:580-286-5929
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0810172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker