Provider Demographics
NPI:1225876980
Name:TELENA, MELLISSA BETTY
Entity type:Individual
Prefix:
First Name:MELLISSA
Middle Name:BETTY
Last Name:TELENA
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 1:1827 S BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-8323
Mailing Address - Country:US
Mailing Address - Phone:580-340-7630
Mailing Address - Fax:580-340-7630
Practice Address - Street 1:1827 S BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-8323
Practice Address - Country:US
Practice Address - Phone:580-340-7630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator