Provider Demographics
NPI:1720384563
Name:BERTRAM-DAVIS, RONNA DEANNE
Entity Type:Individual
Prefix:
First Name:RONNA
Middle Name:DEANNE
Last Name:BERTRAM-DAVIS
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:PO BOX 137
Mailing Address - Street 2:1403 N. 11TH. STREET
Mailing Address - City:RANDLETT
Mailing Address - State:OK
Mailing Address - Zip Code:73562-0137
Mailing Address - Country:US
Mailing Address - Phone:580-281-3273
Mailing Address - Fax:
Practice Address - Street 1:602 SW 38TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6912
Practice Address - Country:US
Practice Address - Phone:580-248-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator