Provider Demographics
NPI:1912227778
Name:HARRIS, ROXANNE DENISE (BS)
Entity type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:DENISE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:DENISE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:1308 NE 43RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-5853
Mailing Address - Country:US
Mailing Address - Phone:405-819-9473
Mailing Address - Fax:
Practice Address - Street 1:1729 W 33RD ST
Practice Address - Street 2:B
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3835
Practice Address - Country:US
Practice Address - Phone:405-216-5608
Practice Address - Fax:405-216-5282
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200123000AMedicaid