Provider Demographics
NPI:1538557202
Name:CLEMONS-COBB, REGINA ANNETTE
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:ANNETTE
Last Name:CLEMONS-COBB
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 1:1003 DENISON ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-5934
Mailing Address - Country:US
Mailing Address - Phone:918-683-4001
Mailing Address - Fax:
Practice Address - Street 1:1003 DENISON ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-5934
Practice Address - Country:US
Practice Address - Phone:918-683-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator