Provider Demographics
NPI:1841076023
Name:YANCEY, NICOLE (MA91368 FLORIDA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:YANCEY
Suffix:
Gender:F
Credentials:MA91368 FLORIDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10607 E 113TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4256
Mailing Address - Country:US
Mailing Address - Phone:305-340-9811
Mailing Address - Fax:
Practice Address - Street 1:2202 E 49TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-8710
Practice Address - Country:US
Practice Address - Phone:407-494-0778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106370225700000X
FLMA91368225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty