Provider Demographics
NPI:1194082982
Name:EITZMANN, SHERYL LYNN
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:LYNN
Last Name:EITZMANN
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 1:2520 BRIAR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-1607
Mailing Address - Country:US
Mailing Address - Phone:580-716-8676
Mailing Address - Fax:
Practice Address - Street 1:1500 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2827
Practice Address - Country:US
Practice Address - Phone:580-762-7561
Practice Address - Fax:580-762-2576
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator