Provider Demographics
NPI:1790427185
Name:CARPENTER, JOHNNA
Entity Type:Individual
Prefix:
First Name:JOHNNA
Middle Name:
Last Name:CARPENTER
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 1:204 WALL ST
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-4400
Mailing Address - Country:US
Mailing Address - Phone:918-649-0018
Mailing Address - Fax:
Practice Address - Street 1:204 WALL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4400
Practice Address - Country:US
Practice Address - Phone:918-649-0018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000000000Medicaid