Provider Demographics
NPI:1265969414
Name:FORD, BLAIRE NICOLE
Entity type:Individual
Prefix:MS
First Name:BLAIRE
Middle Name:NICOLE
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BLAIRE
Other - Middle Name:NICOLE
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:OK
Mailing Address - Zip Code:74061-0068
Mailing Address - Country:US
Mailing Address - Phone:918-892-3914
Mailing Address - Fax:
Practice Address - Street 1:1608 S ELWOOD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4208
Practice Address - Country:US
Practice Address - Phone:918-892-3914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program