Provider Demographics
NPI:1619439510
Name:BALEZENTIS, MIRANDA LEIGH
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEIGH
Last Name:BALEZENTIS
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 1:1635 S 89TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-8251
Mailing Address - Country:US
Mailing Address - Phone:918-645-7183
Mailing Address - Fax:
Practice Address - Street 1:2115 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-2611
Practice Address - Country:US
Practice Address - Phone:918-622-5184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18304183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist