Provider Demographics
NPI:1780972919
Name:HIGGINBOTHAM, IAYISHA RENEA
Entity type:Individual
Prefix:MISS
First Name:IAYISHA
Middle Name:RENEA
Last Name:HIGGINBOTHAM
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 1:1331 N CLASSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106
Mailing Address - Country:US
Mailing Address - Phone:405-601-6710
Mailing Address - Fax:405-601-6711
Practice Address - Street 1:1330 N CLASSEN BLVD
Practice Address - Street 2:SUITE 214
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-6835
Practice Address - Country:US
Practice Address - Phone:405-601-6710
Practice Address - Fax:405-601-6711
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator