Provider Demographics
NPI:1275852626
Name:MAYBERRY, JANEA CRYSTAL
Entity type:Individual
Prefix:MS
First Name:JANEA
Middle Name:CRYSTAL
Last Name:MAYBERRY
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 1:2432 NW 162ND ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1263
Mailing Address - Country:US
Mailing Address - Phone:405-315-0421
Mailing Address - Fax:
Practice Address - Street 1:2432 NW 162ND ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1263
Practice Address - Country:US
Practice Address - Phone:405-315-0421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator