Basic Information
| Provider Information | |||||||||
| NPI: | 1619248952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELBORN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CMII | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 45 PECAN ST | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747017400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809161358 | ||||||||
| FaxNumber: | 5809240972 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 N 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747013801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809313008 | ||||||||
| FaxNumber: | 5809318022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2012 | ||||||||
| LastUpdateDate: | 03/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.