Provider Demographics
NPI:1811368863
Name:DESHAZER, MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DESHAZER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N MICKEY MANTLE BLVD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:OK
Mailing Address - Zip Code:74339-1106
Mailing Address - Country:US
Mailing Address - Phone:918-961-0750
Mailing Address - Fax:
Practice Address - Street 1:124 N MICKEY MANTLE BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:OK
Practice Address - Zip Code:74339-1106
Practice Address - Country:US
Practice Address - Phone:918-961-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0108670163W00000X
MORN2003006810163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse