Provider Demographics
NPI:1710582192
Name:LARGE, SONJA
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:
Last Name:LARGE
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 1:19320 E ADMIRAL PL STE B
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-3240
Mailing Address - Country:US
Mailing Address - Phone:918-340-5503
Mailing Address - Fax:918-340-5505
Practice Address - Street 1:19320 E ADMIRAL PL STE B
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-3240
Practice Address - Country:US
Practice Address - Phone:918-340-5503
Practice Address - Fax:918-340-5505
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator