Provider Demographics
NPI:1992135511
Name:HATHORN, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:HATHORN
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 1:2401 N.W. 39TH ST
Mailing Address - Street 2:103
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-601-9668
Mailing Address - Fax:405-606-7893
Practice Address - Street 1:2401 N.W. 39TH ST
Practice Address - Street 2:103
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:405-601-9668
Practice Address - Fax:405-606-7893
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200527740AMedicaid