Provider Demographics
NPI:1861063638
Name:HAYDEN, SHANTEL MARIE
Entity type:Individual
Prefix:
First Name:SHANTEL
Middle Name:MARIE
Last Name:HAYDEN
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 1:310 NE 28TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-2837
Mailing Address - Country:US
Mailing Address - Phone:405-601-4565
Mailing Address - Fax:877-406-6378
Practice Address - Street 1:310 NE 28TH ST STE 204
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-2837
Practice Address - Country:US
Practice Address - Phone:405-601-4565
Practice Address - Fax:877-406-6378
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200491750AMedicaid