Provider Demographics
NPI:1871117846
Name:MANTOOTH, BEVERLY ANN
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:MANTOOTH
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 1:117801 S 4163 RD
Mailing Address - Street 2:
Mailing Address - City:EUFAULA
Mailing Address - State:OK
Mailing Address - Zip Code:74432-6607
Mailing Address - Country:US
Mailing Address - Phone:918-680-2270
Mailing Address - Fax:
Practice Address - Street 1:117801 S 4163 RD
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-6607
Practice Address - Country:US
Practice Address - Phone:918-680-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty