Healthcare Provider Details

I. General information

NPI: 1457983470
Provider Name (Legal Business Name): MRS. LETA WILLCOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 S FRANKFORT AVE STE 4B
TULSA OK
74120-2428
US

IV. Provider business mailing address

1124 S COLUMBIA AVE
TULSA OK
74104-3929
US

V. Phone/Fax

Practice location:
  • Phone: 918-691-6532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: