Provider Demographics
NPI:1871879130
Name:BURTON, CANDY K
Entity type:Individual
Prefix:
First Name:CANDY
Middle Name:K
Last Name:BURTON
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 1:600 NW 23RD ST STE 108
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-1464
Mailing Address - Country:US
Mailing Address - Phone:405-601-9610
Mailing Address - Fax:405-601-9626
Practice Address - Street 1:600 NW 23RD ST STE 108
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-1464
Practice Address - Country:US
Practice Address - Phone:405-601-9610
Practice Address - Fax:405-601-9626
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK99999171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200301590AMedicaid