Provider Demographics
NPI:1912530379
Name:RODRIGUEZ, AMANDA MARIE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:DYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 LEXINGTON ST TRLR 230
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-8918
Mailing Address - Country:US
Mailing Address - Phone:405-835-1699
Mailing Address - Fax:
Practice Address - Street 1:4400 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5104
Practice Address - Country:US
Practice Address - Phone:405-835-1699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1245445337Medicaid