Provider Demographics
NPI:1003394263
Name:JUSTICE, CHANDRA DAWN (MMP)
Entity type:Individual
Prefix:
First Name:CHANDRA
Middle Name:DAWN
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:MMP
Other - Prefix:
Other - First Name:CHANDRA
Other - Middle Name:DAWN
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MMP
Mailing Address - Street 1:807 N BYRD ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-1411
Mailing Address - Country:US
Mailing Address - Phone:580-371-7362
Mailing Address - Fax:
Practice Address - Street 1:101 N KEMP AVE
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-1719
Practice Address - Country:US
Practice Address - Phone:580-371-7362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK157062225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist