Provider Demographics
NPI:1659654275
Name:HUNIGAN, DEANDRA R
Entity Type:Individual
Prefix:
First Name:DEANDRA
Middle Name:R
Last Name:HUNIGAN
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 1:2625 N PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-2512
Mailing Address - Country:US
Mailing Address - Phone:918-749-0149
Mailing Address - Fax:918-794-0196
Practice Address - Street 1:2625 N PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-2512
Practice Address - Country:US
Practice Address - Phone:918-749-0149
Practice Address - Fax:918-794-0196
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK800673981Medicaid