Provider Demographics
NPI:1255919395
Name:GIST, LORETTA J
Entity type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:J
Last Name:GIST
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 1:41116 E COUNTY ROAD 1240
Mailing Address - Street 2:
Mailing Address - City:KEOTA
Mailing Address - State:OK
Mailing Address - Zip Code:74941-6517
Mailing Address - Country:US
Mailing Address - Phone:918-697-2909
Mailing Address - Fax:
Practice Address - Street 1:41116 E COUNTY ROAD 1240
Practice Address - Street 2:
Practice Address - City:KEOTA
Practice Address - State:OK
Practice Address - Zip Code:74941-6517
Practice Address - Country:US
Practice Address - Phone:918-697-2909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1908224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant