Provider Demographics
NPI:1639682180
Name:CUBIT, WYLEAH YVETTE
Entity Type:Individual
Prefix:
First Name:WYLEAH
Middle Name:YVETTE
Last Name:CUBIT
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 1:933 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-1645
Mailing Address - Country:US
Mailing Address - Phone:405-212-7949
Mailing Address - Fax:
Practice Address - Street 1:933 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-1645
Practice Address - Country:US
Practice Address - Phone:405-212-7949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK004624824Medicaid