Provider Demographics
NPI:1063890473
Name:CRAIG, DARYELLE LENEE
Entity type:Individual
Prefix:
First Name:DARYELLE
Middle Name:LENEE
Last Name:CRAIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DARYELLE
Other - Middle Name:LENEE
Other - Last Name:EANES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:650 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4429
Mailing Address - Country:US
Mailing Address - Phone:918-587-9471
Mailing Address - Fax:918-560-1399
Practice Address - Street 1:11740 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-1820
Practice Address - Country:US
Practice Address - Phone:918-437-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK307491171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator