Healthcare Provider Details

I. General information

NPI: 1700354230
Provider Name (Legal Business Name): VICTORIA TYE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 11/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S CEDAR ST
TAHLEQUAH OK
74464-5152
US

IV. Provider business mailing address

601 S CEDAR ST
TAHLEQUAH OK
74464-5152
US

V. Phone/Fax

Practice location:
  • Phone: 918-478-2474
  • Fax: 918-478-3079
Mailing address:
  • Phone: 918-478-2474
  • Fax: 918-478-3079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: