Provider Demographics
NPI:1629603907
Name:BALENTINE, SANDRA LYNN
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:BALENTINE
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 1:605 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOMINY
Mailing Address - State:OK
Mailing Address - Zip Code:74035-1519
Mailing Address - Country:US
Mailing Address - Phone:918-885-4377
Mailing Address - Fax:
Practice Address - Street 1:605 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMINY
Practice Address - State:OK
Practice Address - Zip Code:74035-1519
Practice Address - Country:US
Practice Address - Phone:918-885-4377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator