Provider Demographics
NPI:1407602337
Name:WALLACE, KESHAWN
Entity type:Individual
Prefix:
First Name:KESHAWN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5370
Mailing Address - Country:US
Mailing Address - Phone:918-986-5918
Mailing Address - Fax:
Practice Address - Street 1:5116 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2077
Practice Address - Country:US
Practice Address - Phone:405-231-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator