Healthcare Provider Details

I. General information

NPI: 1578123022
Provider Name (Legal Business Name): TRACY LYNE COQUILLETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28788 N 3964 RD
OCHELATA OK
74051-2049
US

IV. Provider business mailing address

28788 N 3964 RD
OCHELATA OK
74051-2049
US

V. Phone/Fax

Practice location:
  • Phone: 620-515-3210
  • Fax:
Mailing address:
  • Phone: 620-515-3210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: