Provider Demographics
NPI:1568109486
Name:CHATMAN, MIRACLE
Entity type:Individual
Prefix:
First Name:MIRACLE
Middle Name:
Last Name:CHATMAN
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 1:14300 N PENNSYLVANIA AVE APT 143
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-6058
Mailing Address - Country:US
Mailing Address - Phone:580-917-6543
Mailing Address - Fax:
Practice Address - Street 1:624 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3924
Practice Address - Country:US
Practice Address - Phone:405-799-3379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK318164171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator