Provider Demographics
NPI:1215452305
Name:HERRERA, LORENA ISAMAR
Entity type:Individual
Prefix:
First Name:LORENA
Middle Name:ISAMAR
Last Name:HERRERA
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 1:1326 E THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4732
Mailing Address - Country:US
Mailing Address - Phone:918-378-7413
Mailing Address - Fax:
Practice Address - Street 1:3015 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6317
Practice Address - Country:US
Practice Address - Phone:918-712-0859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200323940Medicaid