Provider Demographics
NPI:1689121832
Name:ISOM, AMELIA MARIE (BA)
Entity Type:Individual
Prefix:MRS
First Name:AMELIA
Middle Name:MARIE
Last Name:ISOM
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 BRYAN DR
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-3462
Mailing Address - Country:US
Mailing Address - Phone:580-920-0909
Mailing Address - Fax:
Practice Address - Street 1:618 BRYAN DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3462
Practice Address - Country:US
Practice Address - Phone:580-920-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
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
OK200453720AMedicaid
OK1679821912OtherNPI