Provider Demographics
NPI:1699404046
Name:MOORE, LAUREN (DPT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84572 S 4660 RD
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-4876
Mailing Address - Country:US
Mailing Address - Phone:918-316-6998
Mailing Address - Fax:
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist