Provider Demographics
NPI:1861796914
Name:DAVIS, MILDRED JEAN (MHR)
Entity type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:JEAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MHR
Other - Prefix:
Other - First Name:MIKKI
Other - Middle Name:JEAN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MHR
Mailing Address - Street 1:1912 BLUEGRASS CT
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-5637
Mailing Address - Country:US
Mailing Address - Phone:405-819-4624
Mailing Address - Fax:
Practice Address - Street 1:1912 BLUEGRASS CT
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5637
Practice Address - Country:US
Practice Address - Phone:405-819-4624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator