Individual
SHALONNA GRISSOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
303 E COURT ST, ATOKA, OK 74525-2047
(580) 889-3399
Mailing address
505 CRESTVIEW, EDMOND, OK 73012
(405) 923-2967
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200287120A
—
OK
Enumeration date
02/22/2012
Last updated
02/22/2012
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