Provider Demographics
NPI:1841548773
Name:RUNYON, TERESA JANETTE
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:JANETTE
Last Name:RUNYON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:JANETTE
Other - Last Name:LUTTRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:507 NE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-1919
Mailing Address - Country:US
Mailing Address - Phone:918-471-9261
Mailing Address - Fax:918-967-8698
Practice Address - Street 1:801 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2351
Practice Address - Country:US
Practice Address - Phone:918-967-8692
Practice Address - Fax:918-967-8698
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management