Provider Demographics
NPI:1639445653
Name:TEAFATILLER, KARRI LEE
Entity Type:Individual
Prefix:
First Name:KARRI
Middle Name:LEE
Last Name:TEAFATILLER
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:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:HAILEYVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74546-0404
Mailing Address - Country:US
Mailing Address - Phone:918-470-4505
Mailing Address - Fax:918-423-5255
Practice Address - Street 1:111 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5363
Practice Address - Country:US
Practice Address - Phone:918-423-5205
Practice Address - Fax:918-423-5255
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK320310303Medicaid