Provider Demographics
NPI:1841851805
Name:FONTE, SHIRLEY A
Entity type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:A
Last Name:FONTE
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 1:3739 NW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-4307
Mailing Address - Country:US
Mailing Address - Phone:405-361-1966
Mailing Address - Fax:
Practice Address - Street 1:4001 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-2685
Practice Address - Country:US
Practice Address - Phone:405-524-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKM000028230Medicaid