Provider Demographics
NPI:1992369359
Name:GOODING, KRISTEN MARIE PAIGE (KRISTEN)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE PAIGE
Last Name:GOODING
Suffix:
Gender:F
Credentials:KRISTEN
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:GIFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 N FAIRLAND ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4203
Mailing Address - Country:US
Mailing Address - Phone:918-825-1405
Mailing Address - Fax:918-876-3436
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4203
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:918-876-3436
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL083238266175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist