Provider Demographics
NPI:1821792821
Name:WHAYNE, JOHNELL MONTREY
Entity Type:Individual
Prefix:
First Name:JOHNELL
Middle Name:MONTREY
Last Name:WHAYNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4919 N ROSEDALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74126-6625
Mailing Address - Country:US
Mailing Address - Phone:918-883-8236
Mailing Address - Fax:
Practice Address - Street 1:4919 N ROSEDALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74126-6625
Practice Address - Country:US
Practice Address - Phone:918-883-8236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator