Provider Demographics
NPI:1689356511
Name:MATTHEWS, IDELLE ANN
Entity Type:Individual
Prefix:MRS
First Name:IDELLE
Middle Name:ANN
Last Name:MATTHEWS
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 1:3903 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1426
Mailing Address - Country:US
Mailing Address - Phone:405-585-2971
Mailing Address - Fax:405-585-2983
Practice Address - Street 1:3903 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1426
Practice Address - Country:US
Practice Address - Phone:405-585-2971
Practice Address - Fax:405-585-2983
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200692960Medicaid
OK201153110Medicaid
OK200560430Medicaid
OK200259560Medicaid
OK200860730Medicaid
OK200868730Medicaid