Provider Demographics
NPI:1447537287
Name:REAL, LAURIE ANN
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:REAL
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 1:1300 S MEKUSUKEY AVE
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-3643
Mailing Address - Country:US
Mailing Address - Phone:580-933-6597
Mailing Address - Fax:
Practice Address - Street 1:401 S MADISON ST
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-2631
Practice Address - Country:US
Practice Address - Phone:580-933-6597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician