Provider Demographics
NPI:1619419041
Name:KEESEE-YOUNGBLOOD, EYDIE FAYE
Entity Type:Individual
Prefix:
First Name:EYDIE
Middle Name:FAYE
Last Name:KEESEE-YOUNGBLOOD
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 1:1436 NW 105TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-5116
Mailing Address - Country:US
Mailing Address - Phone:405-473-6681
Mailing Address - Fax:
Practice Address - Street 1:1436 NW 105TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-5116
Practice Address - Country:US
Practice Address - Phone:405-473-6681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator