Basic Information
| Provider Information | |||||||||
| NPI: | 1518011493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSLEY | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1705 E 19TH ST | ||||||||
| Address2: | STE 302 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188326049 | ||||||||
| FaxNumber: | 9188326055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 E 19TH ST | ||||||||
| Address2: | STE 302 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187487585 | ||||||||
| FaxNumber: | 9187487539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 12/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4522 | OK | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 4522 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200218550A | 05 | OK | MEDICAID |