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General NPI Number Information
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NPI Number | 1043732787
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Entity Type | Individual
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Provider Name | LANDRE TATUM OGLESBY ATC
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Gender | Female
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Dates
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Enumeration Date | 07/14/2017
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 100 N UNIVERSITY DR # 190
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City | EDMOND
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State | OK
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Zip | 73034-5207
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Country | US
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Telephone | 405-974-2188
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Fax |
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Provider Business Mailing Address
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Address Line | 13616 RED BUD RD
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City | CHOCTAW
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State | OK
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Zip | 73020-7166
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Country | US
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Telephone | 405-250-0550
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Fax | 405-250-0550
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000029828
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License Number State |
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