Provider Demographics
NPI:1396251179
Name:ROSE, MICKEETA LASHOONE
Entity type:Individual
Prefix:
First Name:MICKEETA
Middle Name:LASHOONE
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICKEETA
Other - Middle Name:LASHOONE
Other - Last Name:HOLLIMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1022
Mailing Address - Country:US
Mailing Address - Phone:405-248-9368
Mailing Address - Fax:
Practice Address - Street 1:717 NE 79TH PL
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-4106
Practice Address - Country:US
Practice Address - Phone:405-505-3598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-16
Last Update Date:2017-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist