Healthcare Provider Details

I. General information

NPI: 1326615311
Provider Name (Legal Business Name): TARA M BUSSEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W I 240 SERVICE RD
OKLAHOMA CITY OK
73139-7701
US

IV. Provider business mailing address

301 W I 240 SERVICE RD
OKLAHOMA CITY OK
73139-7701
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-9644
  • Fax:
Mailing address:
  • Phone: 405-604-9644
  • 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: