Healthcare Provider Details

I. General information

NPI: 1194494377
Provider Name (Legal Business Name): LACEY HEMBREE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 09/10/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 S UTICA AVE
TULSA OK
74104-4909
US

IV. Provider business mailing address

1623 S UTICA AVE
TULSA OK
74104-4909
US

V. Phone/Fax

Practice location:
  • Phone: 918-982-6800
  • Fax: 918-743-6109
Mailing address:
  • Phone: 918-982-6800
  • Fax: 918-743-6109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3395
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: