Provider Demographics
NPI:1013631746
Name:FISHBACK, EMMA LOUISE
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:LOUISE
Last Name:FISHBACK
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 1:6008 E 62ND ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-2133
Mailing Address - Country:US
Mailing Address - Phone:918-938-2177
Mailing Address - Fax:
Practice Address - Street 1:6216 S LEWIS AVE STE 102
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1075
Practice Address - Country:US
Practice Address - Phone:918-416-4483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator