Provider Demographics
NPI:1679210793
Name:KITTERMAN, MIA NICOLE
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:NICOLE
Last Name:KITTERMAN
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 1:10002 E 116TH PL S
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-2245
Mailing Address - Country:US
Mailing Address - Phone:918-991-2800
Mailing Address - Fax:
Practice Address - Street 1:6216 S LEWIS AVE STE 102
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1075
Practice Address - Country:US
Practice Address - Phone:918-960-7852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKB29600228OtherSOONER CARE