Provider Demographics
NPI:1639689672
Name:RIDGEWAY, AMBER LYNN
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LYNN
Last Name:RIDGEWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:LYNN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1016 N RANGE RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-1985
Mailing Address - Country:US
Mailing Address - Phone:405-762-1927
Mailing Address - Fax:
Practice Address - Street 1:1016 N RANGE RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-1985
Practice Address - Country:US
Practice Address - Phone:405-762-1927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKYUN823211514OtherBLUE CROSS BLUE SHIELD