Provider Demographics
NPI:1780807354
Name:MATHIA, LORETTA SUE
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:SUE
Last Name:MATHIA
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 1:25510 S 607 LN
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-0262
Mailing Address - Country:US
Mailing Address - Phone:918-786-2908
Mailing Address - Fax:
Practice Address - Street 1:25510 S 607 LN
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-0262
Practice Address - Country:US
Practice Address - Phone:918-786-2908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver