Provider Demographics
NPI:1992474969
Name:MUKOMBE, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MUKOMBE
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 1:820 N EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3828
Mailing Address - Country:US
Mailing Address - Phone:918-510-2958
Mailing Address - Fax:
Practice Address - Street 1:3400 DESKIN DR # 8295
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-8295
Practice Address - Country:US
Practice Address - Phone:405-701-8530
Practice Address - Fax:405-701-8529
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-12
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children