Healthcare Provider Details

I. General information

NPI: 1891312641
Provider Name (Legal Business Name): TAMMY DIANA ZOLLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2020
Last Update Date: 06/28/2020
Certification Date: 06/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 E 91ST ST
TULSA OK
74133-5790
US

IV. Provider business mailing address

5406 W 90TH ST N
PORTER OK
74454-2696
US

V. Phone/Fax

Practice location:
  • Phone: 918-307-6390
  • Fax:
Mailing address:
  • Phone: 918-521-3612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number78080
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: