Provider Demographics
NPI:1992975387
Name:WASSON, REIDA LORI
Entity type:Individual
Prefix:
First Name:REIDA
Middle Name:LORI
Last Name:WASSON
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 1:2702 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-6408
Mailing Address - Country:US
Mailing Address - Phone:405-320-5040
Mailing Address - Fax:
Practice Address - Street 1:2702 S 17TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-6408
Practice Address - Country:US
Practice Address - Phone:405-320-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK809172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker