Provider Demographics
NPI:1881120426
Name:BALENTINE, FERRELL LACE (BA)
Entity type:Individual
Prefix:MISS
First Name:FERRELL
Middle Name:LACE
Last Name:BALENTINE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 MILLS AVE
Mailing Address - Street 2:203 MILLS AVE
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2737
Mailing Address - Country:US
Mailing Address - Phone:918-721-8197
Mailing Address - Fax:
Practice Address - Street 1:203 MILLS AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2737
Practice Address - Country:US
Practice Address - Phone:918-721-8197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator