Provider Demographics
NPI:1699293068
Name:HERRING, DIAMOND CHA
Entity type:Individual
Prefix:
First Name:DIAMOND
Middle Name:CHA
Last Name:HERRING
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 1:5505 MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-5508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5505 MAIN STREET
Practice Address - Street 2:102
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115
Practice Address - Country:US
Practice Address - Phone:405-609-6595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1Medicaid